PBS | Getting to Know Your Business

Address
Street Address Address Line 2 City State ZIP Code
Phone
Email*
Website
Need to add another location?
- Yes
- No
Location #2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Need to add another location?
- Yes
- No
Location #3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Market Area Information
Area's Served*
On separate lines, enter the trade area's your typical patients come from.
For example:
- Denver
- Boulder
- Fort Collins

Click the (+) icon to the right to add additional lines if necessary.
Potential to Expand Reach*
- Yes
- No
What areas would you like to expand to?
Click the (+) icon to the right to add additional lines if necessary.

Patient Statistics
How many prospective patients contact you each month? (walk-ins, phone calls, Internet leads, emails, etc.)
Of these potential patients/clients, what % come in for an initial consultation or schedule an appointment?*
What percentage of your prospects that come in for a 1st appointment convert to a paying client/patient (what is your typical "closing ratio")?*
How are new patients currently sourced?*
For example- 80% referral, 5% newspaper ad, 10% mailers, 3% website, 2% other

Click the (+) icon to the right to add additional lines if necessary.
Source Percentage (%)
How many patients do you work with each month?*
How many patients does your business have the capacity to work with each month?*

Patient Value:
What is your typical annual gross revenue per patient?*
What is the estimated lifetime value of your average patient?*
(in other words, what is the total dollar value of the entire future relationship with a patient?).

Marketing:
In a typical year, what is your budget/expenditure for the following. If nothing, please enter $0:
Yellow-Pages, Dex or other phone book advertising*
Website Hosting*
Web Advertising (SEO, PPC, Email Blast-etc.)*
Initial Website Creation*
Initial Logo Creation (or other branding expenses)*
Video Production*
Coupons (cost of mailing them out)*
Coupons (total opportunity cost of having given discounts for services)*
Radio or TV advertisements*
Direct Mail campaigns*
Networking*
Staff expense to manage advertising*
Any other marketing you have done
Click the (+) icon to the right to add additional lines if necessary.
Type of Marketing Annual Cost ($)
What advertising channels have led to the best success?
What advertising channels have been the biggest disappointments?
What services would you like to see more production from (example. I'd like to see more neuropathy patients)?

Existing Contracts
Do you currently have any active or outstanding advertising contracts or commitments?*
- Yes
- No
Existing Contracts/Commitments*
Please describe the outstanding advertising contracts/commitments. (Term, Company, etc.)

Contact Information

Source	Percentage (%)

Type of Marketing	Annual Cost ($)