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Business Name *

Email *

Phone *

What are your primary goals for the next two years? *

Revenue, new offices, strategy, etc.

How many locations do you have? *

What type of marketing agency are you looking for? *

A vendor who can help render services
A true partner who understands my industry and can help me reach my goals
Not sure

How do you reach your ideal customers currently? *

Mailers
TV
Radio
Billboards
Social Media
All of the above

What are you currently doing to convert leads to patients? *

What is the follow-up process like? How is this tracked? Do you discount your services? Do you focus on quality care? Please give a thorough response so we can best understand your practice's model.

On a scale from 1-10 how would you rate your current Facebook strategy? *

Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10

On a scale from 1-10 how would you rate your current Google Ad strategy? *

Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10

On a scale from 1-10 how would you rate your current SEO strategy? *

Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10

Who are your main competitors? *

How many quality leads do you want per month? *

From new marketing efforts, how many quality leads would you need in order to meet goals?

What is your current conversion rate from Exam to Starting Treatment? *

Between 25-50%
50%-75%
75-95%

If you see 100 new patients per month, how many actually start treatment?

What do prospects find interesting about you? *

What sets you apart from the competition?

What is your current annual production? *

What is the area you need the most help in? *

Are you the decision maker for the practice? (If not, please have the practice owner on the call.) *

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