Customer Registration

Prefix

First name

Middle name

Last name

Credential

Do not use

Organization

Mobile

Work Phone

Home phone

Other phone

Fax

Country

Address

Address Line 2

City

State

Zip Code

Website

License Number

Text Permission

Yes No

Text Phone Number

Ethnicity

Asian/Pacific Islander Black or African American Hispanic or Latino Hispanic or Latino|Black or African American Other White White|Hispanic or Latino White|Native American or American Indian

Languages Spoken


	English
	English\|Arabic
	English\|Farsi
	English\|French
	English\|French\|Arabic
	English\|German
	English\|German\|Other
	English\|Hindi
	English\|Japanese
	English\|Mandarin
	English\|Other
	English\|Spanish
	English\|Spanish\|French
	English\|Spanish\|German\|Other
	English\|Spanish\|Other
	French
	Other
	Spanish

Chiropractic College


	Canadian Memorial Chiropractic College
	Cleveland Chiropractic College Kansas City
	Cleveland Chiropractic College LA
	D’Youville University
	Life Chiropractic College West
	Life University
	Logan University
	Los Angeles College of Chiropractic
	National College of Chiropractic
	National University of Health Sciences
	National University of Health Sciences of St. Petersburg
	New York Chiropractic College
	Northeast College of Health Sciences
	Northwestern Health Sciences University
	Palmer College of Chiropractic - Davenport Campus
	Palmer College of Chiropractic - Florida Campus
	Palmer College of Chiropractic - West Campus
	Parker University
	Sherman College of Chiropractic
	Southern California University of Health Sciences
	Texas Chiropractic College
	University of Bridgeport College of Chiropractic
	University of Western States

Diplomate


	Diplomate American Board of Chiropractic Internists (DABCI)
	Diplomate American Board of Chiropractic Orthopedists (DABCO)
	Diplomate American Chiropractic Board of Clinical Nutrition (DABCN)
	Diplomate American Chiropractic Board of Nutrition (DACBN)
	Diplomate American Chiropractic Board of Radiology (DACBR)
	Diplomate American Chiropractic Board of Sports Physicians (DACBSP)
	Diplomate American Chiropractic Neurology Board (DACAN or DACNB)
	Diplomate American Chiropractic Rehabilitation Board (DACRB)
	Diplomate American College of Chiropractic Orthopedics (DACO)
	Diplomate Chiropractic Board of Clinical Nutrition (DCBCN)
	Diplomate International Chiropractic Pediatric Association (DICPA)
	Diplomate International Academy of Medical Acupunture (Dipl.Ac. IAMA)
	Diplomate International Board of Chiropractic Neurology (DIBCN)
	Diplomate International College of Chiropractic Pediatrics (DICCP)
	Diplomate of the International Academy of Neuromusculoskeletal Medicine (DIANM)
	Diplomate of the National Certification Commission for Acupuncture and Oriental Medicine (Dipl Ac NC
	Fellow International Academy of Medical Acupunture (FIAMA)
	Fellow of the International Chiropractic Pediatric Association (FICPA)
	Fellow of the International Chiropractors Association (FICA)
	International Chiropractic Sport Science Diplomate (ICSSD)
	Level 1 Certified, American Chiropractic Rehabilitation Board (ACRB 1)
	Level 2 Certified, American Chiropractic Rehabilitation Board (ACRB 2)

Techniques


	Active Release Technique (ART)
	Acupuncture
	Advanced Activator Methods & Acupuncture
	Applied Kinesiology
	Atlas Orthogonists
	B.E.S.T.
	Bioenergetics
	Brimhall
	CBP
	Cold Laser
	Cranial Sacral
	Decompression
	Diversified
	DNFT
	DOT Exams
	Drop Techniques - Other
	Drop Techniques – Thompson
	Dry Needling
	Extremity Adjusting
	FAKTR-PM
	Flexion/Distraction
	Flexion-Distraction - Cox
	Flexion-Distraction – Leander
	Full Spine
	Gonstead
	Graston
	Instrument Adjusting - Activator
	Instrument Adjusting – Atlas Orthoganal
	Instrument Adjusting - Impulse
	Instrument Adjusting – Other
	Instrument Adjusting – Pro-Adjuster/Sigma
	Instrument Adjusting – Torque Release
	Integrative
	Kinesiotaping
	Logan Basic
	Low / Non Force Techniques
	Motion Palpation
	Myofascial Release
	NET
	Nimmo
	Palmer Package
	Pettibon
	Sacro Occipital Technique (SOT)
	Soft Tissue
	Thompson
	Toggle
	Upper Cervical - NUCCA
	Upper Cervical - Other
	Upper Cervical –Toggle
	Webster

Committee Interest


	Acupuncture Committee
	Awards Committee
	Cash Practices
	Editorial Committee
	Education Committee
	Insurance Committee
	Legislative Committee
	Medicare
	Membership Committe
	Personal Injury
	Philosophy & Ethics Committee
	Practice Management/New Docs
	Public Relations Committee
	Research
	Social Media
	Web Committee
	Workers Comp

Use email address for VCA Communications

Yes No

Include Email Address in Directory/Public

Yes No

Your Current role in Practice

Associate Owner Partner

I identify mostly with the following

Established Practitioner Established Practitioner Looking to Exit Practice (Sell, Retire, Etc.) Established Practitioner Seeking Growth New Practitioner (0-3 years) Other


	English
	English\|Arabic
	English\|Farsi
	English\|French
	English\|French\|Arabic
	English\|German
	English\|German\|Other
	English\|Hindi
	English\|Japanese
	English\|Mandarin
	English\|Other
	English\|Spanish
	English\|Spanish\|French
	English\|Spanish\|German\|Other
	English\|Spanish\|Other
	French
	Other
	Spanish