Avanmed | Questionnaire

Avanmed Questionnaire

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PRACTICE INFORMATION
Name*
First Last
Practice Legal Name*
Practice Address
Practice New Patient Phone Number
Emails for new patient leads: (add all that apply)
Zip Codes to Include in Marketing: (List all that apply)
Zip Codes to Exclude from Marketing: (List all that apply)
Services which you offer (list all that apply)

PATIENT PERSONA
Male % of Patients
Female % of Patients
Average income level of patients/ideal patients
Describe 3 of ideal patients & their traits (Job industry, income level, hobbies, clubs, etc)

PRACTICE OPEARATIONS
Current weekly new patients #:
Goal new patients per week #:
Payment Options (Select all that apply)
- Commercial
- Medicare
- Medicaid
- Cash/Self Pay
Commercial Insurance Carries you’re affiliated with:
Do you offer Telemedicine:
- Yes
- No
Do you have an online schedule link:
- Yes
- No
Online Schedule Link