Campbellsville University

Doctor Profile

Doctor's Name*

First Last

Office Name*

Office Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone Number*

Office Email*

Chiropractic School you graduated from*

Graduation Date*

6. Do you accept Medicare? Medicaid? Personal Injury? Workers Compensation? Commercial Insurance (ie. BlueCross, United, Humana, etc.)?*

Yes

No

If yes, which ones?

Do you have a working x-ray machine?*

Yes

No

If yes, Digital or plain films?

Digital

Plain Films

Main Chiropractic techniques used in practice?*

How many patient visits do you see in a typical week?*

How many new patients do you see in a typical month?*

File Check List

File I*

Max. file size: 100 MB.

Upload the three patient files. Remember to use the File Check List as a cover sheet.

File II*

Max. file size: 100 MB.

Upload the three patient files. Remember to use the File Check List as a cover sheet.

File III*

Max. file size: 100 MB.

Upload the three patient files. Remember to use the File Check List as a cover sheet.

Teaching and Learning Questionnaire

The College of Chiropractic program provides a professional education comprised of the knowledge, skills and attributes necessary for one to practice chiropractic effectively, ethically, and safely as a portal-of-entry, primary care chiropractic physician.

The following questions help Clinical Education better understand your unique clinic and how you and your staff will support our students learning needs.

As a chiropractor, describe how you recognize the need for (detect) and treat (correct) a chiropractic subluxation. Describe how your treatment fits into the preservation and restoration of health.*

Describe specific types of chiropractic adjustments utilized in your practice to facilitate neurological and biomechanical integrity.*

Please list and explain the adjunctive therapies used in your clinic to support patient care needs.*

Describe how you promote the concepts of health and wellness in your clinic.*

Describe how you and your clinic promote interdisciplinary care.*

Describe the use of outcome measure in your treatment plans.*

Describe what evidence informed practice means to you and how you support this model in your practice (diagnostic and treatment procedures, etc.).*

Describe what is most rewarding / fulfilling about providing chiropractic care.*

Describe the atmosphere/culture you and your staff promote in your clinic.*

Provide examples of how you will integrate an intern into your practice.*

Describe how you will provide close observation, mentorship, and respectful feedback to interns as they learn under your supervision.*

Strong business skills are a very important part of opening and running a practice. Describe how you and your staff will provide learning opportunities to gaining business skills and knowledge*

Provide a Teaching Philosophy Statement or Statement of Purpose.*

Please upload the following additional items:

CV (resume)*

Max. file size: 100 MB.

Copy of current Chiropractic license*

Max. file size: 100 MB.

Evidence of malpractice insurance*

Max. file size: 100 MB.

Copy of your current BLS certificate*

Max. file size: 100 MB.

Community Based Clerkship- Doctor Application - Chiro

Doctor Profile

File Check List

Teaching and Learning Questionnaire