To Start April 1, Sign Up No Later than Wednesday, March 27 To view results, click here. Your Name: Practice Name: Email: Office Phone Number: Fax: Practice Website: Office Address: City: State: Zip Code: Card: Choose a Card American Express Discover Master Card Visa Card #: No spaces Exp. Date: MMYY Security #: By submitting this form, you give ChiroTrust permission to charge you $397 per month to build your practice. If you ever want to stop, just let us know and there will be no further charges to your credit card. It’s that simple. I Agree