Dr. James Fedich Membership Application Form

Please fill out the form below to apply for a membership plan, *are required fields.


Applicant Information:

Today's Date:

Membership Options:

Silver

$250/Month

Comes with
E-mail

Choose Plan

Gold

$350/Month

Comes with
E-Mail and Phone

Choose Plan

Platinum

$750/Month

Comes with both
E-mail, Phone, PLUS 2 Days in
Dr. Fedich's clinic a year!

Choose Plan

Please answer the following questions below:

1. Current gross income:*
Below $200,000 $200 - $400,000 $400 - $600,000 $600 - $800,000 Over $800,000

2. How many patient visits a week do you see?*
0 - 50 51 - 100 101 - 150 151 - 200 201 - 250 Over 250

3. How many new patients per month do you see?*
0 - 50 51 - 100 101 - 150 151 - 200 201 - 250 Over 250

4. What are your collection goals in the next 24 months?*
Below $400,000 $400 - $600,000 $600 - $800,000 $800,000 - $1 million $1 million - $1.2 million Over $1.2 million