Diabetic Leads Order Form

Diabetic Leads Order Form

Fill out the form accurately for campaign registration
Name*

First NameLast Name
Who is your IMO or BGA?*
Referred by:*
Relationship to Referral: My referral is:*

my uplinemy downlinean agent colleagueOther
Your campaign will begin as soon as funds are confirmed. If you wish to schedule a specific date and time for this campaign to begin, choose the date and time below.

MonthDayYear
Date
Hour MinutesAM/PM Option
Resident State?*
States Licensed? (Check all that apply) NOTE: CHECK ONLY THE STATES FROM WHICH YOU WISH TO RECEIVE LEADS*

ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Mobile Number (You will receive automated text alert in real-time)*
Office Number (Enter number you wish to be given to your lead if they choose to call you directly)
E-mail*
example@example.com
Do you use an online scheduling software (I.e. Calendly, etc) that you would like for us to share with each new lead prospect?*

YesNo, I would like assistance on creating a calendar for booking.I do not want my leads to have the option to schedule themselves.
Provide the link to your scheduler here:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Choose Order Type
prevnext( X )
Diabetic LeadsLeads are generated from compliant ads marketed across social media platforms or keyword search Google traffic. Minimum of (20). TEMPORARILY ALLOWING (10)
$25.00 Quantity
Item subtotal:$0.00



3-Page Mobile StoryStoryboard containing your image, DCS branding, license images, and integrated booking calendar. Purchase includes html files. Hosting available. See example below.
$100.00 Quantity



Personal Landing PageLanding page with DSC branding. You may add your personal branding as well. Includes your choice of "Book Now" button directing traffic to your scheduler, or integrated Calendly for booking. Includes html files. Hosting available. See example below.
$250.00 Quantity



Subtotal

$0.00

Tax

$0.00

Total

$0.00
Sample mobile story: https://diabeticeverything.com/paul

Sample landing page: https://go-excel.com/paul-landing-page.html
Should be Empty: