New patient referrals to our clients: 798,747 Referrals as of 12/19/2018

Delivering Successful Clinical and Career Strategies

Primary Spine Care Qualified

Application

Name:

Address:

Phone:                                                                   Email: 

State(s) and License(s) #'s: 

Malpractice/Licensure actions against your license:

None ______ (please initial)

or describe date, action and circumstances briefly and understand we will be verifying all below with your licensure board.

1. 

2. 

3. 

4.

I have taken or equivalent (please check off) and supply the curriculum of equivalent course

__ Primary Spine Care 1

__ Primary Spine Care 2

__ Primary Spine Care 3

__ Primary Spine Care 4 (live only)

__ Primary Spine Care 5

__ Primary Spine Care 6

RULES: To qualify, you must have taken any of the 4 above. Attendance will be verified

Signature

Date: 

PLEASE FILL THIS OUT & SEND WITH A $500 FEEPAID TO PROCESS

Bank Routing #:                                        Bank Account #:

Credit Card #:                                                      Exp. Date:

Billing Zip Code:

Recognized by:

Cleveland University, Kansas City -Chiropractic and Health Sciences

Academy of Chiropractic- Post Doctoral Division

Please fill out and email to DrMark@AcademyOfChiropractic.com or fax to 661-843-1062

PLEASE TAKE NOTICE: © Copyright CMCS Management, Inc - Dr. Mark Studin 2014- This information is intended for educational purposes only. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon is prohibited.