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X-Ray Survey

First Name

Last Name

Email

Doctor Cell

Lead Shielding Plan Needed?

Yes

No

Clinic/ Facility Name

State Facility Number

Clinic Phone

Mailing Address

City

State

Postal / Zip code

Chiropractic Focus/Method

Coach/Coaching affiliation:

Contractor Contact Name

Contractor Phone

Expected Completion Date

Clinic Address

City

State

Postal / Zip code

Check if address different for clinic.

Superintendent Contact Name

Superintendent Phone

Requested Equipment

Equipment currently installed (if any)

Number of days open per Week

Anticipated Maximum # of Patients per day (X-Ray)

Requesting Quote

X-Ray Room Layout (Upload)

Upload File

Upload supported file (Max 15MB)

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Home
Products
Software Training
Support
- iCRco Tips and Tricks
About
- Testimonies
X-ray FAQs
Survey Form
Contact Us
- Information Request
More

Use tab to navigate through the menu items.

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