Your Business Information
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
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
Business Phone Number
*
Business E-mail
*
Website URL
*
Facebook Fan Page URL
*
Name of the Doctor (If applicable)
First Name
Last Name
Name of Marketing Manger who will follow up with leads. If there are more than one please list them all here:
Main Notification E-mail
Would you like to get text message notifications when a lead comes in?
Yes
No
Not right now
Main Notification Mobile #
-
Area Code
Phone Number
Your Contact Info
Your Name
*
Your Title
*
Owner
Manager
Other
Your Email (If different than business email)
Best Phone # To Reach You (Mobile):
*
Additional Info:
Other information we'll need to setup and run your campaign properly.
URL For Funnel
*
Do you have someone in your office that can follow up with leads? If so what is his/her name and email?
We'll need to create a subdomain for your funnel. Where is your domain name registered and who handles that for you? (e.g. special.yourdomain.com)
Are there any other emails we should send leads to?
What are the zip codes or a radius for the areas you serve? (This is used for your facebook ad targeting.)
Have You Made Chris or Phil a Manager on Your FB Page?
*
Yes - Chris
Yes - Phil
Not Yet
Need Help Doing So
Don't Have a Page Yet
Having Trouble Doing So
How Much Are You Willing To Spend Per Month On Your Ads?
*
How Can We Get Some Pictures of You In Action At Your Office?
What Is The Best Irresistible Offer You Can Make For New Patients For $21?
What Else Can You Offer On The Thank You Page To Encourage People To Call and Set An Appointment Immediately?
Any Additional Notes:
LPM Team Member You're Working With:
Chris
Phil
Terri
Paul
Cameron
Get Started!
Should be Empty: