Tell Us More About Your Practice!

Please note: Some questions on this form require multiple answers. To see all available options, click on the answer box to open the dropdown, then select all answers that apply to you.

This form should not take more than 7 minutes.

About Your Practice 🩺

First Name *

Last Name *

Email *

PLEASE USE THE SAME EMAIL ADDRESS FROM INITIAL CONTACT FORM

What is the name of your practice? *

What type of practice do you run? *

How long have you been open? *

Are you a solo practitioner or do you have providers *

How big is your team? (Including you) *

How many treatment rooms do you have? *

What are your current clinic hours? e.g Mon-Fri 9am-5pm *

Do you accept insurance, cash pay, or both? *

Insurance only

Cash pay only

Both

Your Numbers 📈

Roughly how many new patients do you see per month right now? *

What's your average patient visit value? *

What would you consider a 'good month' in Gross Revenue? (ballpark is fine) *

What is your #1 service or treatment, the one you want more patients for? *

What You've Tried 🤔

Have you ever tried a marketing agency or third party consultant? *

Yes

If Yes, how was your experience?

Are you still working with them

Yes

What was the biggest challenge? *

Have you tried radio or TV advertising? (or other media)

Yes

Currently

If Yes, please select all media advertising you are using.

Do you have any published print ads? *

Yes

If yes what publishers have you used?

What's the #1 thing you've tried that felt like a complete waste of money? *

What's the one marketing thing that HAS worked, even a little? *

Goals & Pain Points 🎭

What's the #1 reason you're looking for marketing help right now? *

What does success look like for your practice 12 months from now? *

What's your biggest pain point with marketing your practice? *

How do / will you measure marketing success?

How confident are you in your current marketing?

Not ConfidentVery Confident

What do you think is holding you back from growing faster?

Let's Make Sure We're a Fit 🦄

Are you the decision maker when it comes to marketing spend at your practice?

Yes, it's my call

I share the decision

No (someone else decides)

Are you ready to invest in done-for-you marketing in the next 30 days? *

Are you happy for us to stay connected?

Yes sure!

No thanks.

How did you hear about PinkMarketing.Life? *

Who Referred you?