Marketing

Contact Information (* required fields)

Doctor's Name*

Clinic Name:*

Address:*

City, State Zip:*

Office Phone:*

Office Fax:

Cell Phone:

Email:

Best time that you can be reached:

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Please rate yourself below:

	Poor	Fair	Good	Excellent	Outstanding
Your Performance
Your Staff's Performance
Patient Retention
Collections
Services
Clinic Appearance
Advertising & Marketing
Procedures & Systems
Computer Systems
Technical Experience
Goals & Assessment
Obtaining New Patients
Insurance Procedures

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Challenges & Your Practice

Which do you feel are the biggest challenges in your practice: (check all that apply)
Consultation	Examination	Report of Findings
Examination procedures	Patient contr ol	Referrals
Insurance procedures	Advertising	Increased Income
Personal injury practice	Industrial practice	Associate doctor practice
Staff acquisition	Staff training	Staff management
Location evaluation	Sign evaluation	Bldg. Plan/recommendations
Floor plans	Overhead control	Money management
Keeping "The dogs off"	Selling your practice	Other

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Marketing & Advertising Challenges

Which have created challenges to your Marketing/Advertising campaigns: (check all that apply)
Newspaper Advertising	Patient Referrals	Brochures and handouts
Radio or TV advertising	Patient Education Classes	Patient follow-ups
Website	Speaking Engagements	I have no marketing plan!

Your Goals

Do you have a specific written plan outlining your goals and a strategy to improve your practice?				yes	no
Are you happy with the amounts of new clients that you are attracting and the amount of older clients that you are retaining in your practice?				yes	no
Do you have any concerns at all regarding you practice/profession?				yes	no
Have you ever considered having a practice management consultant helping you achieve your goals?				yes	no
If someone could help you improve your business, increase your profits, retain your current clients as well as get you new clients - would you be interested in learning more?				yes	no
Don't you think it is time to stop procrastinating and do something that could have a profound impact on your practice?				yes	no

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Misc.

Please check the statement(s) below that best apply to you and your practice:
I'm ready to join!
I'm interested, but still have a few questions
I need to work out a financial arrangement
I'm not interested at this time
Thank you, but I just want the half hour consultation with the Doctor/Director