Clinic Application Form

1

Your Name* This field is required.

First Name

Last Name

2

Contact Number* This field is required.

Please enter a valid phone number.

3

Email ID

example@example.com

4

City* This field is required.

5

Clinic Name* This field is required.

6

Clinic Website Url* This field is required.

7

What type of clinic do you own* This field is required.

Dermatology Clinic

Aesthetic Clinic

Plastic Surgery Clinic

Hair Transplant Clinic

Dental Clinic

8

Approximately how many patient enquiries do you receive per month?

Less than 50

50–100

100–300

300+

9

Are you prepared to invest ₹30,000+ per month in management fees and a structured ad budget to scale your Clinic?* This field is required.

Yes

No

10

What’s the biggest digital marketing challenge you're facing right now

Need more patient enquiries

Low Google visibility

Poor Google Maps ranking

Ads not generating patients

Low repeat patients

Facebook Lead Quality issue

11

Have you previously worked with an agency* This field is required.

Yes

No

12

Terms and Conditions* This field is required.

13