Extreme Makeover Form

Extreme Makeover Form

If you have an existing aquatic clinic or pool practice in need of an emergency turn-around, fill out this form so we can determine how best to help you.
First Name
Last Name
Email
example@example.com
Title
Facility
How many years in business?

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Problem Identification
What challenges are you currently experiencing?

Low patient census Declining reimbursements Staff (high turn-over, wet-hair syndrome, etc.) Business competition Other option
Explain your problems in detail

Desired Outcomes
Heading
How can we help?

Give us new programming options Get us more publicity Give us marketing help Give us staff training Give us billing help Give us cost-reduction strategies Get us more physician referrals Get us more community awareness/involvement Other option
Explain how we can help

Products and Services Desired
What products are you interested in?

Policy and procedure manual customized for your operations Client brochure (pdf) Physician referral brochure (pdf) Press release 60-second radio spot (mp3) Site certification 1-year phone and email support ATU training discounts Other option
What other services can we provide that aren't listed above?

Final Thoughts
Other details?
What other details would you like us to know about your unique situation?
Should be Empty: