This form is to apply for the Skyrocket Facebook Ads Intensive Program with Dr. Maddy Roth. Submitting this form does not guarantee admittance to the program. Upon admittance you will be notified via email within submitting this with your next steps.

Are you a Pelvic PT/OT?*
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
Mobile or Brick & Mortar?*
  • S-corp
  • LLC/PLLC
  • Sole proprietorship
  • Nonprofit
  • C-corp
  • Other
  • No elements found. Consider changing the search query.
  • List is empty.
How long has your clinic been open?
Influx?*
  • Yes!
  • No
  • Maybe
  • No elements found. Consider changing the search query.
  • List is empty.
Can you take an influx of new patients?
Staff Support*
  • I have admin support.
  • I have admin support + other clinicians
  • It's just me :)
  • I have other clinicians, but no admin.
  • No elements found. Consider changing the search query.
  • List is empty.
Patients Per Week*
  • 0-4
  • 5-10
  • 10-20
  • 20-35
  • 35+
  • No elements found. Consider changing the search query.
  • List is empty.
Do you have Facebook?*
  • yes
  • no
  • No elements found. Consider changing the search query.
  • List is empty.
If the answer is yes, please state which type of CRM (ex: Hubspot, Go High Level) and which company you purchased it from.