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1
Are you currently running your own business?
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Yes
No
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2
What healthcare services do you offer?
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eg: Physiotherapy, Dental, Podiatry, Chiropractic
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3
How long have you been running your business?
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Less than 1 Year
2-4 Years
4-8 Years
More than 10 Years
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4
What is your current revenue per year?
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$0 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000+
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5
How many people are on your team? (part-time, full-time)
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Just Me
1-3 Team Members
4-10 Team Members
More than 10 Members
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6
If we were talking in 12 months from now…What would your ideal business look like?
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7
What is your website?
Enter URL here
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8
Name
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First Name
Last Name
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9
What is your best email?
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example@example.com
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10
Where are you located?
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USA/Canada (+1)
UK (+44)
Australia (+61)
New Zealand (+64)
Africa (+27)
USA/Canada (+1)
UK (+44)
Australia (+61)
New Zealand (+64)
Africa (+27)
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11
What's the best phone number to call?
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12
What's the best phone number to call?
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(Please include your country code)
Area Code
Phone Number
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13
What kind of situation are you in right now?
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I want more new patients
I want my practice to depend on me less
I want to hire and grow a larger team
All of the above
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