AMPED Membership Relief Questionnaire
The leadership of AMPED has identified a few select groups of docs that are particularly vulnerable to financial struggles placed upon them by the COVID-19 crisis. We are asking that you answer the following questions honestly so that we can identify real need. These relief decisions will be made on an individual basis, with the goal of identifying anyone in need, and providing them a temporary reduction in their membership costs.
Email *
What is your Name? *
What is the name of your Practice? *
What is the best number at which to reach you? *
In which of the following categories are you? *
In what State are you practicing? *
Has your State mandated the closing of chiropractic offices? *
Will you have to lay off employees from your loss of revenue? *
How many discontinuations and how much revenue have you lost from those accounts due to COVID-19? *
Do you have the margin to pay your overhead AND full AMPED membership for the next month or two? *
Do you have any other details about your current situation that we need to know in order to best help you or others in need of relief? *
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