COVERING / ASSOCIATE DOCTOR SURVEY 
Print this form from your browser and send it along with the $25 registration fee to:
Secure Relief, Inc.
201 Compo Rd. South
Westport, CT 06880

Name: __________________________________________________________

S.S. #:    ______-_____-__________
D.O.B.:   ____/_____/________
Address: _______________________________________
_______________________________________________
City: ______________________________________
State: _______     Zip:  _______________________ 
Phone #:    

Business:  (_______)  ______ - ______________

Fax:          (_______)  ______ - ______________

Home:      (_______)  ______ - ______________
Licensed__________________ License #s________________________
States

Malpractice Insurance: ?   Yes     ?   No
Company_____________ Amount______

BACKGROUND INQUIRY: If you answer yes to any of the following questions please provide a detailed explanation on a separate sheet.
1] Have you ever surrendered or had your state license refused, restricted, suspended or revoked?
?   Yes     ?   No

2] Has any action[s] ever been taken against you by the licensing board of any state?
?   Yes     ?   No

3] Have you ever been reprimanded or had your membership refused, suspended, or revoked by any professional organization?
?   Yes     ?   No

4] Have you ever been named as a party in a malpractice suit? 
?   Yes     ?   No

5] Have you ever been convicted of a crime other than a minor traffic offense?
?   Yes     ?   No

6] Have you ever been treated for alcoholism or narcotic addiction?
?   Yes     ?   No

7] Do you have any physical, mental, or addictive problems that may interfere with carrying out your professional responsibilities? 
?   Yes     ?   No

8] Have you ever been the subject of investigation by any peer review committee?
?   Yes     ?   No
9] List memberships in national, state, and local professional organizations.
 
 
 
 
 
PROFESSIONAL PROFILE:
Availability: 
Days:
 
Hours: 

Previous commitments:
Techniques practiced with competency--- please list:
 
References: Please list a minimum of two doctors with their phone numbers for whom you have provided chiropractic services.
 

  
Graduated from_____________________ chiropractic college.
YR:
 
Practice experience: 
# of years:
# of months:
 
Certification[s] and post-doctoral education
 
Daily volume able to handle: 
 
Travel restrictions: 30mi.....50mi..... None
 
Are you willing to do "spinal screenings"?
 
Please add any additional information that makes you special or unique. [for instance bilingualism]
 
 
Signature:____________________________Date:_________________________
 
THANK YOU FOR YOUR TIME AND ATTENTION. WE LOOK FORWARD TO DOING BUSINESS WITH YOU! PLEASE REMEMBER TO ENCLOSE YOUR $25 REGISTRATION FEE.