Diabetic Leads Order Form

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.

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 [Minimum = 4 states]*

Mobile Number (You will receive automated text alert in real-time)*

Format: (000) 000-0000.

Office Number (Enter number you wish to be given to your lead if they choose to call you directly)

Format: (000) 000-0000.

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:

Paste your LinkedIn link here:

Do you want us to automatically send your Ethos link to your lead?*

YesNo

Insert your private Ethos link here:*

Choose Order Type

Diabetic Leads [Quantity = 20-49]

Leads are generated from compliant ads marketed across social media platforms or keyword search Google traffic. Minimum of (20).

$19.00 Quantity
Item subtotal:$0.00

Diabetic Leads [Quantity = 50 and up]

Leads are generated from compliant ads marketed across social media platforms or keyword search Google traffic. Minimum of (50).

$15.00 Quantity
Item subtotal:$0.00

3-Page Mobile Story

Storyboard 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 Page

Landing 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