Contact Information
Name
*
First Name
Last Name
Title
*
Please Select
Owner
Therapist
Office Manager
Other
Practice Name
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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District of Columbia
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Hawaii
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Maine
Maryland
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Michigan
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Montana
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of motor therapists (PT/OT) in the practice.
*
Number of clinic locations
*
How did you hear about us?
*
Please Select
Begin Begin Method Email
Conference
Facebook
Google Search
Instagram
Other Pediatric Professional
Personal Referral
Other
Who can we thank?
*
Does your practice currently work with infants?
*
Yes
No
No, but interested in serving this population
Are you interested in adding a new revenue stream?
*
Yes
No
Do you see a benefit in treating infants with plagiocephally/torticollis?
*
Yes
No
We currently treat these diagnoses
Is there any additional information you would like to share about your practice to help facilitate a more productive call (ie: pain points, barriers to growth, etc.)?
*
How many salaried/hourly employees do you have?
Who is your biggest referral source?
Prospect Type
Please Select
Warm- personal referral
Cold -found us on their own
Frozen -BBM email
Status
Please Select
Initial Contact
2nd contact
F/U needed
Discovery Call Scheduled
Discovery Call Completed
Zoom Call Scheduled
DM sent
Cold Call Made
Sleep
In Negotiations
Proposal Sent
Licensing Agreement Sent
Agreement Signed
Payment Info Sent
Payment Received
Implementation
Closed - Lost
Completion- Won
Implementation Team
Please Select
Jodie
Additional Discovery Notes
Enter initials, date, who you spoke with and your note here. Include which sales person wrote each note for clear identification.
Zoom Date
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Month
-
Day
Year
Date
Action Date
-
Month
-
Day
Year
Date
Product Type
Pro Package
Elite Package
Entry Type
Manual
Jotform
Signed License Agreement
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Date Contract Begins
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Month
-
Day
Year
Date
Date Contract Ends
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Month
-
Day
Year
Date
Implementation Email Sent
-
Month
-
Day
Year
Date
Welcome Box Mailed
-
Month
-
Day
Year
Date
What are your goals for the next 3 years? (more private pay/groups/more infants-less autism/hiring new therapists/filling schedules/etc)
What is the helmet environment in your area? A lot of providers? Who is near by? What do pediatricians in your area think about helmets?
Who are your biggest competitors? What do they offer that you don't? What are YOU known for in your community?
Is hiring motor therapists a challenge in your area? If you got really busy, would you be able to staff the uptick easily?
Get a good feel for their current staff. Who has potential for infant therapy? What is their availability/potential? Can they hire? Train others?
Anyone else you would like to invite to the zoom product demo?
Pros/Cons of partnering with this group.
Once the form is submitted you will be brought to the calendar to schedule your discovery call.
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