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Heber City, UT 84032
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Design Questionnaire (NM & NR)
Practice Name
(Required)
First
Website
Main Practice Phone Number
(Required)
Is this the phone number you want us to forward our call tracking numbers to? If not, please provide the number we should use.
Yes
Other
Practice Management Software
Physical Address
Street
City
State
Zip Code
Billing Address
Consent
Is the billing address the same as the physical address?
Street
City
State
Zip Code
Mailing Address
We will be sending you sample packets of your postcards each month. Is your mailing address the same as the physical address?
Yes
No
If no, please provide your mailing address:
Street
City
State
Zip Code
Primary Contact
Primary Contact Name
First Name
Last Name
This should be the primary person that will be running point and provide approvals on the dental postcard campaigns.
Primary Contact Phone
Primary Contact Cell Phone
Primary Contact Email
(Required)
Consent
Is there anyone else who is authorized to approve postcard designs and maps?
Secondary Contact Name
First Name
Last Name
Secondary Contact Phone
Secondary Contact Cell Phone
Secondary Contact Email
Dental Team
Please provide for your team members that should have dashboard access and receive alerts.
Names and Titles of Dental Team (Dr, Hygienist, Assistants, Team Members)
Full Name
Role
Email
Names and Titles of Dental Team (Dr, Hygienist, Assistants, Team Members)
Full Name
Role
Email
Names and Titles of Dental Team (Dr, Hygienist, Assistants, Team Members)
Full Name
Role
Email
Additional Team Members:
About Your Practice
What is the emphasis of your practice?
Select all that apply by holding "control" (Windows) / "command" (Mac) key while choosing.
General Dentistry
Implants
Extractions
Cosmetics Dentistry
Pediatric Dentistry
Orthodontics
Invisalign
First year average patient value:
*Most practices average between $2000-4000 based on how much specialty work they do in-house vs. referring out. Practices who do a lot of implants, cosmetics, invisalign, etc. are typically closer to $4000, where practices who stick to mainly bread and butter dentistry tend to be closer to $2000.
In your opinion, why should a patient choose you instead of your competitors?
What additional benefits do you feel make your practice unique?
Has your practice received any local awards or community recognition?
If so, what are they?
How do your patients pay for treatment?
% Insured, % FFS, % Medicaid, Financing Options, etc.
What are the demographics of your current patients?
Income level? Family structure? Ethnicities?
New Move In Template Selection
Click Here to View Available New Move In Templates
Selected Template
N/A
Set A
Set B
Set C
Set D
Set E
Set F
Set J
Set K
Set H
Set I
Set K - Ortho
Set L - Ortho
Should we match the color scheme and branding of your website or do you have a different color scheme in mind?
New Move-In Welcome Message for Card
*There is a message from the doctor on the back of each card. Would you like to use the standard message above or customize your own?
Special Offer(s) Ideas:
Is there any additional messaging you would like to use in your campaign?
Do you have doctor, staff or office photos to be considered for your card?
These could be images of the doctors), family, team, office, etc. Please also include a high quality logo file. Make sure all images are hi-resolution, print quality.
Yes, I'll send them to you right away or upload them below.
Not yet, but we plan on getting some take soon.
No, and we will not be getting any taken soon.
Logo File & Photo Upload
Drop files here or
Select files
Max. file size: 256 MB.
