"NextLevel Practice Solutions" Assessment Form

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Are You Ready to Transform Your Practice Into the Practice of Your Wildest Dreams?Waste No More Time.... Let's Go!!!
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Owner's Name (Practitioner)* This field is required.
First Name
Last Name
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2nd Co-Owner's Name. * This field is required.If no co-owner place N/A in both fields
First Name
Last Name
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3rd Co-Owner's Name.* This field is required.If no co-owner place N/A in both fields
First Name
Last Name
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Practice Corporate Name* This field is required.
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Practice dba Name* This field is required.If No DBA type N/A
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Practice Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Practitioner's Direct Corporate Email Address* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
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Practitioner's Practice Phone Number* This field is required.
Please enter a valid phone number.
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Practitioner's Mobile Phone Number* This field is required.For the Convenience of Text Messaging
Please enter a valid phone number for text messaging.
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Type of Practice* This field is required.
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Website Address* This field is required.
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Actual State of Incorporation* This field is required.
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How long have you owned your Practice?* This field is required.
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How many Practice locations do you have?* This field is required.
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Have you contemplated establishing additional practice locations?* This field is required.
YESNO
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Have you completely reported the ownership and management information of your business to the U.S. Treasury Financial Crimes Enforcement Network (FinCEN); regarding the Corporate Transparency Act (CTA) of 2024?* This field is required.Click Here, to access the application to begin the process of compliance, or access via our website.
YESNO
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If you haven't, would you like for our corporate legal team to assist you in complying; to avoid a fine of $500/day and a Penalty of $10,000 or 2 years imprisonment?* This field is required.Click Here, to access the application to begin the process of compliance, or access via our website.
YESNO
19
How many employees do you have on staff?* This field is required.
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Do you currently offer No Cost, No Risk, Interest Free Pay Advances to your staff members?* This field is required.
YESNO
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If you answered No, would you like to become a "Hero Employer" and offer No Cost, No Risk, Interest Free Pay Advances, to your staff members* This field is required.Studies show that it helps to retain employees
YESNO
22
Are you currently in need of a commercial loan, equipment financing, or any type of capital or financing?* This field is required.Financing for any need.
YESNO
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If Yes, what kind and in what amount? If No, put N/A* This field is required.
24
Have you made arrangements with anyone, to assist you in receiving up to $26K per employee retained in 2020 and 2021, regarding the Employee Retention Credit Program?* This field is required.
YESNO
25
Would you like for us to assist you with obtaining up to $26K per Employee, via the ERC Program?* This field is required.Time is running out on this government program. Therefore, you must act expeditiously!
YESNO
26
What is the average amount, in credit card processing fees, you paid, in the last two (2) months, according to your statements?* This field is required.We can eliminate up to 95% of your processing fees
27
Have you ever worked with a full service company like ours, that basically provides Business, Marketing, and Financial Services; along with Consultation and Coaching?* This field is required.
Yes
No
28
If you checked No, simply input N/A. If you have, who was it and why aren't you working with them, now?* This field is required.
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Do you currently offer financing to your patients?* This field is required.
Yes
No
30
If you offer financing, is it in house or via another source? If it's through another source, who is the finance provider?* This field is required.
31
Does your practice need the services of an experience debt collector, to collect your delinquent debt?* This field is required.
Yes
No
32
Does your practice need loan servicing, for your in-house financing?* This field is required.
Yes
No
33
Does your practice need the service of an experienced Tax Specialist?* This field is required.
Yes
No
34
Are you working with anyone to handle your Online Reputation and Reviews?* This field is required.
Yes
No
35
Are you Marketing and Promoting your Reputation, via a Reputation Marketing Campaign?* This field is required.
Yes
No
36
Are you pro-active with gathering Reviews from your patients; and are you Responding to All of your Reviews (good & bad), on a daily basis?* This field is required.
Yes
No
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Why should prospective patients choose you and your Practice vs. your Competitor?* This field is required.
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What is currently the biggest challenge or problem, in your Practice?* This field is required.
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Are you working with anyone to handle your Marketing and Advertising Campaigns?* This field is required.
Yes
No
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If yes, to the above question, then with who? If you answered no, type N/A.* This field is required.
41
Are you advertising via any of the following? Check all that applies.* This field is required.
Google
Yelp
Social Media
Television & Radio
Magazine
Billboards
Mailouts
Newspaper
Other
42
If you are Advertising on Social Media, check all the media sites, that apply.* This field is required.
Facebook
Instagram
LinkedIn
Twitter
Tic Toc
Other
43
How many new patients are you averaging per week?* This field is required.
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How many High-Ticket Procedures, Services, Or Treatment Plans, are you averaging per week?* This field is required.
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What is your conversion rate?* This field is required.
example: 2/10, 3/10
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What are your three (3) Most Profitable High-Ticket Procedures, Services, or Treatment Plans, and what are you charging for each? This will help us to promote these high-ticket services, for you, more effectively. The goal is to substantially increase your Case Acceptance Rate for high-ticket services/treatment plans/procedures.* This field is required.
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What is the lifetime value of a patient to your practice? Place N/A if your practice doesn't necessarily bank on repeat patients, as with cosmetic surgeons.* This field is required.
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With which sources are you currently advertising? Check all that applies, please.* This field is required.
Google Ads
Yelp
Facebook
Instagram
LinkedIn
Display Ads
Radio or Television
Twitter
Other
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Are You Satisfied with your Marketing and Advertising Results?* This field is required.
Yes
No
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What's the monthly amount of your current Marketing/Advertising budget?* This field is required.
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What's your average monthly revenue, over the past three (3) months?* This field is required.
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Where would you like your average monthly revenue to be in the next 3 months?* This field is required.
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Are you able to consistently accommodate your patients, in a timely manner, in accordance to their scheduled appointment time?* This field is required.
Yes,
No
All of the time
Most of the time
Some of the time
It varies
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What would you honestly consider to be your weaknesses in your practice?* This field is required.
55
What would you honestly consider to be your strengths, in your practice?* This field is required.
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Would you consider yourself to be detailed oriented?* This field is required.
Yes
No
57
What clear and distinctive advantage does your practice have over your competitors? What's your Unique Selling Proposition USP?* This field is required.
58
List the top three (3) things you would like to improve in your practice.* This field is required.
59
What are your pain points?* This field is required.
60
Are you interested in becoming #1 in your market area, by dominating it?* This field is required.
Yes
No
Maybe
It depends
61
What do you feel it will take, to become #1 in your Market, and to Dominate it?* This field is required.
62
What is your current case acceptance rate, on your high-ticket procedures? * This field is required.
63
Do you have a dedicated staff member handling patient services* This field is required.
Yes
No
64
Is your Staff professionally trained to covertly upsell your patients to high-ticket procedures, services, or treatment plans?* This field is required.
Yes
No
65
Approximately, how many patients do you have in your database, that you can re-target, for additional services?* This field is required.
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Do you need more space or medical equipment?* This field is required.
Yes
No
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Would you have an interest in becoming a coach or consultant to others in your profession, to create additional income?* This field is required.
Yes
No
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How many days a week are you working, in your practice?* This field is required.
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How many days a week would you ideally prefer to work, in your practice?* This field is required.
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What are your realistic SHORT-TERM goals and in what time frame would you like to accomplish them?* This field is required.
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What are your realistic LONG-TERM goals and in what time frame would you like to accomplish them?* This field is required.
72
If we can present a sound and realistic plan, for you to achieve and accomplish your short-term and long-term goals, backed by our Lifetime Guarantee, would you be interested in moving forward with our services?* This field is required.
Yes
No
73
What percentage of your monthly revenue are you willing to spend on Marketing & Advertising, to reach and/or exceed your goals?* This field is required.
74
What would you realistically expect in return, for your Marketing & Advertising dollars?* This field is required.
75
If you could wave a magic wand, today, what one skill would you manifest within yourself that could be done with excellence, in your practice; you feel would help you the most, to at least double your revenue? What skill would that be? Let's be completely honest and specific, please.* This field is required.
76
What area of your practice would you like to see strengthen, to achieve more sales and revenue.* This field is required.
example: Education, another dentist, etc.
77
What software tools/technology are you currently using in your practice and from who?* This field is required.
78
Who or What are you using to Manage, Build, Market, and Promote your Reputation; and are you happy with the results?* This field is required.
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How important do you think it is to have a great reputation?* This field is required.
Extremely Important
Some what important
It has no effect on my practice
Not Important, at all
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Who or what are you using to Drive Traffic to your practice and website; and are you happy with the results?* This field is required.
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Who or what are you using to Re-target traffic to your practice or website; and are you happy with the results?* This field is required.
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What is the #1 passion you have for your practice? In other words, what drives you, everyday to perform? What puts a smile on your face?* This field is required.
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What added-value elements does your practice provide, to your patients?* This field is required.
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What exactly would you like to see NextLevel accomplish, for you and your practice? Be specific, please.* This field is required.
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Are you interested in saving up to 95% of the processing fees you've been paying?* This field is required.
Yes
No
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CONGRATULATIONS, on completing your Practice Assessment Form!!! If you have any thoughts, questions, and/or concerns please let us know here.... Keep in mind, your answers will be kept strictly confidential, inside our company, once you become a client. if you don't become a client or no longer remain a client, this Assessment Form will be Destroyed and you will be notified that it has been deleted. Oh!... Book your Online Appointment with us, to discuss both assessment forms, to get you started, ASAP. One last thing... over the 33+ years we have been providing services to our clients, we have adopted and offer many services, either in house or via our business partnerships. Therefore, if you need anything for your practice, feel free to ask us if we offer it. We would greatly appreciate it. Thank you, for completing this form.
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