Patient Questionnaire | Lifted Logic

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Comments

This field is for validation purposes and should be left unchanged.

How long has your practice been open?

Years Open*

Not yet open

<1 Year

1-2 Years

3-5 Years

5-10 Years

11-15 Years

16-20 Years

21+ Years

Which verticals most closely apply to your practice?

Select all that apply

Verticals*

Medical Aesthetics

Physical Therapy

Chiropractic

Dentistry

Plastic Surgery

Primary Care

Wellness Center

General Surgery

Other

What are your goals for your practice over the next 1-3 years?

Select all that apply

Goals*

Improve Operations

Improve Patient Retention

Improve Sales

Improve Profit Margin

Improve Staff Retention & Culture

Increase Volume of New Leads

Work Less Hours

Sell, or prepare to sell

How many locations do you have?

Locations*

2-3

4-5

How many employees do you have per location?

Employee Count*

What is currently your primary source of new leads/business?

Lead Source*

Word of Mouth

Traditional Advertising

Digital Marketing / Advertising

Physician Referrals

Other

What is the current Lifetime Value of your patients?

Lifetime Value*

What is your current total marketing + advertising spend per year?

Current Spend*

Let us know where to send your results!

First Name*

Last Name*

Email*

e.g. info@liftedlogic.com

Phone*

e.g. (555) 555-5555

By submitting this form, you agree that Lifted Logic Medical may contact you by phone, text, or email regarding your inquiry, requested services, consultation scheduling, account-related updates, and other service-related communications. Message frequency varies. Msg & data rates may apply. Reply HELP for assistance and STOP to opt out at any time.

Marketing Messages

I agree to receive promotional & personalized marketing messages from Lifted Logic Medical. Consent is not a condition of purchase. Message frequency varies. Msg & data rates may apply. Reply HELP for assistance and STOP to opt out at any time.

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