Strategy Session Form

First Name *

Last Name *

Personal Phone Number *

Email *

Practice Name *

Your Position *

Practice Website *

How Did You Hear About Dr. Nick/LVRG Media and What Triggered You To Schedule This Strategy Session *

What is your average number of patient VISITS per WEEK? *

What is your average number of NEW PATIENTS per MONTH? *

NEW - How Much In Collections Have You Averaged Per Month In The Past Six Months?

$0-10K

$10-20K

$20-30K

$30-50K

$50-75K

$75-100K

$100K+

What top three places do your new patients come from? *

In a perfect world, what would you like to accomplish in the next 12 months when it comes to your online marketing? *

Why is now the time to do something about your online marketing? *