New Client Questionnaire

Please Plan On 20 - 30 Minutes To Complete

Before we can help you, we need a bit of information to understand more about your practice, and your goals.

Your Practice Name

Address Of Your Practice

Practice Website

Primary Contact's Name

Person for Room 118 to contact for questions.

Primary Contact's Email Address

Primary Contact's Telephone Number

Primary Contact's Title

Age of Practice

Age of practice in years (approximate).

Select Two Brand Attributes

Select two brand attributes that best describe how you position your practice.

What Is Your Practice's Clinical Focus?

Select all that apply.

How Many Locations Do You Have

How Many Operatories Do You Have

Approximately How Many Patients Consider You Their Primary GP?

On Average How Many New Patients Do You See Each Month

Approximately How Many Patients Do You See Each Month in Total

Total Collections For The Last 12 Months

Diagnostic & Preventative Care (% of Collections)

Approximately what percent of your collections are for Diagnostic & Preventative care?

Restorative Care (% of Collections)

Approximately what percent of your collections are for Restorative care?

Endodontic Care (% of Collections)

Approximately what percent of your collections are for Endodontic care?

Periodontic Care (% of Collections)

Approximately what percent of your collections are for Periodontic care?

Prosthodontic Care, Excluding Implants (% of Collections)

Approximately what percent of your collections are for Prosthodontic care, excluding Implant Dentistry?

Maxillofacial Prosthetics (% of Collections)

Approximately what percent of your collections are for Maxillofacial Prosthetic care?

Implant Dentistry (% of Collections)

Approximately what percent of your collections are for Implant Dentistry?

Oral & Maxillofacial Surgery (% of Collections)

Approximately what percent of your collections are for Oral & Maxillofacial Surgical care?

Orthodontic Care (% of Collections)

Approximately what percent of your collections are for Orthodontic care?

Sleep Therapy Care (% of Collections)

Approximately what percent of your collections are for Sleep Therapy and related care?

Other Care (% of Collections)

Approximately what percent of your collections are for other care?

What Is Your Collections Goal Over The Next 12 Months

How Much Do You Spend On Social Media Ads Every Month?

How Much Do You Spend On Paid Search Ads Every Month

How Much Do You Spend On Other Forms Of Advertising Every Month?

Do You Have An Active Patient Referral Program

Do You Have An Active Clinical Referral Program

Do You Have A Documented Lead Generation & Sales Process

Do You Use A CRM or Tools To Track Patient Leads

Do You Actively Use Marketing Analytics To Track & Attribute Patient Leads

What Practice Management System Do You Use

What Email Marketing System Do You Use

Please Select Any Of The Following Tools That You Currently Use

In Your Own Words, Describe Your Long Term Practice Goals

From A Practice Growth Perspective, If You Could Change Three Things Today, What Would They Be

What Has Been Going Well From A Marketing Perspective

What Requires Immediate Attention From A Marketing Perspective

What Is Your Approximate Annual Marketing Budget

Is There Anything Else We Should Know To Best Help You Define A Growth Plan

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