I request consideration to receive the FREE mini-briefing DVD to learn more about the franchise opportunity of a HealthSource Chiropractic franchise(s) in the comfort and privacy of my home. I understand that in the 1 hour Mini-Briefing DVD that I will view, certain proprietary information, trade secrets, copyrighted marketing materials, confidential financial data and similar information will be disclosed, and I warrant that I will treat all such disclosures as privileged and confidential. In viewing the Mini-Briefing DVD, I am merely watching to learn more about HealthSource Chiropractic. Under no circumstances will I be allowed to purchase a franchise merely by watching the DVD, and I incur no financial obligation whatsoever by viewing the mini-briefing DVD.

    I agree [must be checked to receive DVD]

Please complete and submit the form below to receive your mini-briefing DVD:

Dr. Name:
Practice Name:
Practice Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Years in Practice
Check One:	Single Office Multi-Office
Check One:	Solo Practitioner Have  Associate Doctor(s)
	Have you ever been sanctioned, fined, or suspended by a state chiropractic board, sanctioned, fined, prosecuted by any other regulatory agency, convicted of a misdemeanor or felony, or sued civilly?
Check One:	Yes No
	If Yes, please describe:
Form Security Code:
Enter Security Code:

This is the easy part. We recommend you grab an hour of time whereby you can sit, listen, take notes, hit the pause button and discuss with your spouse any questions you come up with, and become familiar with the HealthSource Chiropractic franchise. A great deal of information is shared on the D VD. Take your time and learn.

If, after watching the Mini-Briefing DVD, you have more questions, and you probably will, just pick up the phone and give us a call at 440-967-5458. Any member of our team will be more than happy to help you. The rules of succeeding in chiropractic have changed drastically. Wouldn’t it be helpful if you knew the new rules? Just part of our job is to teach you those new rules, which are changing constantly today.

Your decision to view the HealthSource Mini-Briefing DVD is only to look at, examine, and learn about a HealthSource franchise. It is not a decision to join HealthSource at this time. No franchises will be sold immediately after viewing the Mini-Briefing DVD.