Practice Name *

Owner First Name *

Owner Last Name *

Email (Same You Used To Pay) *

Staff Member Contact Name *

Office Phone Number *

Practice Website URL *

Personal Cell Phone Number (Emergencies Only) *

Street Address (EX: 117 N Patterson) *

City (EX: Valdosta) *

State (EX: Ga) *

ZIP (EX: 31602) *

Country *

Which email(s) would you like us to send lead notifications to?

Which phone number(s) would you like us to text lead notifications to?

Cross Streets?

What are you closest Landmarks? How would you describe where your clinic is located to someone who has never been in the area before? *

What Languages Are Spoken At The Clinic? *

What type of practice? *

What type of payment methods do you offer? *

Cash Pay

Insurances

Both

Guarantee? *

10 Over 40

30 Over 90

60 Over 180

None of the Above

Parking Information *

Clinic Entrance Location *

What pay model? *

Retainer

Pay Per Show

Retainer + Rev share

Same Day Appointments? *

Yes

No

Inform Practice

ISA? *

Yes

No

Do you do Direct Billing?

Yes

No

Did you sign up for our Virtual Front Desk? *

Yes

No

Amount Per Show (If Applicable)

Has the client paid?

Amount Paid (Ex: $3000)

Monthly Ad Budget

Launch Call Date *

How did you find out about Paradigm Development Group?

Referral Name?

Who they are (The person being spoken to)

Notes for Account Manager