Your Title/Position *

Owner/Co Owner

Medical Director

Practice Manager

What best describes you? *

I am a medspa that offers weight loss

I am a wellness Brick N Mortar

I am Telehealth Clinic

I am brick N mortar + Telehealth

Social Media URL'sPlease provide all social media links from Instagram, Facebook, Twitter... *

Your Direct Email *

Legal Business Name. (Needs to be exact. if this is incorrect it can delay our launch process by 7-14 days) *

EIN Number (Please skip this if you're not in the US) - This if for A2P 10DLC Verification* *

STATE REGISTERED ADDRESS FOR A2P SUBMISSION: *

Street Address

*

City

*

State

*

Country

*

Postal Code

Clinic Location: Ignore if the same as state above^

Street Address

Clinic Postal / Zip Code

Website URL *

Main Clinic Phone Number *

Main Clinic Email *

Your Direct/Home Phone Number *

Facebook Page URL

BRICK N MORTAR ONLY: What Are The Available Parking Options For Clients? (e.g., on-site parking, nearby parking garages, street parking, parking fees, valet service, etc.)"

How long have you been in business? *

Preferred Communication For Our Team To Contact You *

Call

Text/SMS

Email

If selected other, please specify

BRICK N MORTAR ONLY: What's the #1 Service or Treatment you want us to focus on to sell the most of and what price points?

BRICK N MORTAR ONLY: If we find a better opportunity in the area or we find the area too competitive for your #1 preferred, what are the 2 other services treatments we can pivot to?

What are the names and emails of the people performing the treatments in your office? (e.g. Nurse Practitioner Katy who has helped treat 3,000+ patients with their skin concerns) - It's VERY important they understand the entire process and that we know who the patients should be expecting when they come into the office

BRICK N MORTAR ONLY: Please provide a link to any initial patient paperwork they need to complete prior to coming into your office

Do you offer telehealth/virtual consultations? *

Yes

No

Considering It

List Your Business Hours *

Max new patients per WEEK you can handle: *

BRICK N MORTAR: Preferred consultation type: *

In Clinic

Telehealth

Both

Do you have a current sales system in place? Or a sales process for when patients show up to calls? *

Yes

No

Who handles booked appointments?

Who handles Patient Follow Up

Do you offer financing? If YES which provider do you use *

Upload Your Clinic Logo

PDF, PNG, GIF, JPEG or JPG ( max 5 Files )

Brand colors if any (Optional)

Competitor clinics you’d like to outperform (URLs, optional):

Appointment Length, Details, & Buffer Time (e.g. 60 Minute appt time with 15 minute buffer in between...)

What EMR/EHR or backend do you use right now? *

TO PREVENT BOOKING DELAYS:

Please invite our technical lead, [email protected], to your EMR/EHR as an admin. Should be pretty straightfoward in the staff tab the way you'd invite your staff normally.

This is REQUIRED so we can prevent any double bookings, save time on our onboarding call, and prevent any technical errors with the interaction.

Do you currently have a FACEBOOK Business Portfolio, Ad account & page? *

TO PREVENT AD LAUNCH DELAYS:

Please invite [email protected] to your Facebook Business Manager.

Visit: business.facebook.com. In the left menu tab, select People, then Add our email above with full control.

This is REQUIRED. We want to launch you ASAP and save you all the time we can with the technical nuance.

What is your marketing process? In other words... please explain EVERYTHING A-Z that you have in place or have tried to generate new patients *

Breakdown of how previous campaign or marketing strategies have performed: how much did you spend, how many leads, how many consults, how many people did you close, & how much revenue did you generate? *

Last Calendar Month - How Much Total Revenue did you do (this is how much literally hit your business bank account last month TOTAL from front end sales, existing clients, product sales... everything all together). *

What is your realistic goal revenue in 90 Days? *

Do you have Employees? - If YES, please list all emails you want us to invite to our communication platform *

Anything we should NOT say or promise in your marketing? (optional)

Do you have any existing ads you like the look of? If yes, upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Please attach a Google Sheet link to your Patient Database or existing lead list so we can run our ''Fast Cash Play'' to tell them about the offer we're promoting. Upload your customer list

Do you service Spanish speaking patients or just English? *

BOTH

Spanish

English

Billing Contact Phone *

List ALL softwares, tools, app you use *

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I confirm I am authorized to make marketing and billing decisions for this clinic. All information in this form is accurate to the best of my knowledge. I understand that Patient Near Me generates qualified appointments only and does not provide medical services.