First Phone Call Lead Capture Form

"Is now a bad time to ask you a few questions to make sure we are a good fit?"

Today's Date *

Who is filling out this form? *

Lead Information

First Name *

Last Name *

Is this a returning patient? *

STEP 1: FIND THE PROBLEM

BE THE GUIDE. BUILD THE GAP .

ASK: "WHAT'S BEEN BOTHERING YOU THE MOST"

THEN LET THEM TALK.

What's been bothering you the most? (external) *

What is causing you to seek treatment?

Where are you hurting most? *

Pain Point

Where do they want to focus?

How long have you been suffering? *

When did this begin?

What have you already tried? What helps? *

Is this injury related to

Work Injury? Surgery? Etc.

What was the date of Injury or Surgery? *

STEP 2: FIND THE IMPACT (THIS IS CRITICAL)

ASK: "HOW IS THIS AFFECTING YOUR DAY-TO-DAY LIFE?"

"WHAT HAVE YOU STOPPED DOING BECAUSE OF THIS?"

THIS IS WHERE THE SALE STARTS

How is this affecting your day-to-day life? (Internal) *

What have you stopped doing because of this?

STEP 3: FIND THE WHY (GO DEEPER)

ASK: "WHY IS THIS IMPORTANT TO YOU?"

"WHAT WORRIES YOU IF THIS DOESN'T IMPROVE?"

THIS IS WHERE THE SALE STARTS

What are you afraid of happening if this keeps going the way it is? *

If you do nothing , what worries you most?

What is your ideal outcome? *

Where do they want to be?

Help me understand what life would look like for you if this was 100% resolved: *

Run a 5K? Walk with a friend? Get back to pickleball? Host a family dinner without needing to sit down? Are you hiking? Playing golf? Vacationing? Walking around Disneyland? Paint the picture!

STEP 4: BUILD THE GAP

REFLECT BACK:"SO WHAT I'M HEARING IS , YOU'RE DEALING WITH ___, IT'S AFFECTING , AND YOU'RE WORRIED THAT IF YOU DO NOTHING_"

THEY MUST FEEL UNDERSTOOD. THIS IS THE SUMMARY NARRATIVE

Is there anything else I should know to best help you? *

STEP 5: SHOW THE FUTURE

PAINT THE OUTCOME: "JUST IMAGINE BEING ABLE TO________"

WALK WITHOUT PAIN, PLAY PICKLEBALL AGAIN, TRAVEL CONFIDENTLY.

STEP 6: ADDRESS FEARS (BEFORE THEY SAY THEM)

SAY: "A LOT OF PEOPLE WORRY THIS WON'T WORK...." OR "SOME PEOPLE FEEL OVERWHELMED GETTING STARTED."

NORMALIZE RESISTANCE.

STEP 7: PRESENT THE PLAN (NOW AND ONLY NOW)

"HERE'S WHAT I RECOMMEND_" THIS IS HOW WE GET YOU BACK TO__"

TIE IT DIRECTLY TO THEIR GOALS. NOT: "WE DO EMTT AND SHOCKWAVE..."

STEP 8: ASK FOR THE DECISION

"DOES THAT SOUND LIKE WHAT YOU ARE LOOKING FOR?"

PAUSE. OBJECTIONS?

"I UNDERSTAND. OUT OF CURIOSITY, WHAT PART ARE YOU WANTING TO THINK THROUGH?"

Background

Have you been to PT before?

How did you find us? *

Lead Source

What was your experience like? Did it help?

Lead Source Details

Returning Patient? How long ago?

What Services are you most interested in?

Physical Therapy (General)

EMTT

Shockwave

Red Light/PEMF

Stretch

Performance/Return to Sport

Wellness/Nutrition

Bone Density

Dry Needling

Other

What other service are you interested in?

Call Outcome

What is the outcome of this call? *

IE Date

IE Time

Don't enter as: "7" "12" or use "AM/PM"

DV Date

DV Time

Offer Type

Payment Type *

Payment Not Discussed Detail *

Are they a candidate for Direct Pay?

Candidate for Direct Pay

Why didn't they book? *

Follow-Up Date* *

Insurance Call Back Date

Follow-Up Details* *

Add more details as to why this lead did not book. The goal is to continue nurturing this lead, add helpful details here.

Hook for Follow-Up (mystique) *

something specific, something emotional, something unresolved

Why are they not a fit? *

Primary Insurance Company

Secondary Insurance Company

Primary Insurance ID Number

Secondary Insurance ID Number

Primary Insurance Group Number

Secondary Insurance Group Number

Primary Insurance Phone Number

Secondary Insurance Phone Number

Primary Policy Holder Name

Scondary Policy Holder Name

Primary Policy Holder Date of Birth

Secondary Policy Holder Date of Birth

Work Comp Company Name

Work Comp Claim Number

Work Comp Adjuster Name

Work Comp Adjuster Phone Number

Lien Information (Auto Accident or Personal Injury)

Additional Details

Email *

Phone *

Please verify correct input

Date of birth *

Address *

Street Address

City

State

Country

Country

Postal Code