2016 Goals Questionnaire

Hello and thank you for your interest in our Doctorpreneur™ Program. This marketing and practice development program was designed to help create Stability, Growth & Financial Freedom in your practice. To get started, please fill out this brief questionnaire. Upon completion, someone from our office will contact you to schedule your "Get Ready For Success" telephone consultation with Dr. Nelligar.

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* 1. Contact Information

Name:

Company:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Email Address: *

Phone Number

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* 2. Credentials

M.D.

D.O.

D.C.

D.D.S.

Other (please specify)

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* 3. Contact Information

Main Office Phone:

Back Office Phone:

Cell Phone:

Fax:

Email:

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* 4. Do you have a website?

Yes

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* 5. If yes, what is the address of your website (e.g. www.domainanme.com)

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* 6. Is a company optimizing your website regularly for keywords relating to your products and services so your website can be found on Google, Bing and Yahoo?

Yes

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* 7. If no one is presently optimizing your website, is this a new service you would be interested in help to get more business?

Yes

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* 8. Provide us with at least two competitor websites in your area

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* 9. Demographics:

a. What is the general population of your town?

b. What is the economic status of the people in your area?

c. What is the average income of the people in your area?

d. What secondary languages are spoken in your area?

e. Do most people drive or use public transportation?

f. What percentage of your practice is...

- Medicare

- PPO

- HMO

- Cash

- Indemnity Insurance

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* 10. General Practice Information:

a. How many years are you in practice?

b. What type of practice do you presently have?

c. How many hours a week do you work in the practice?

d. Is this a new practice you are opening or are you adding new services to an existing practice?

- If this is a new practice, what type of practice are you opening (e.g. medical spa, wellness center, pain relief office)?

- If this is an existing practice what new services will you be adding (aesthetic or pain relief)?

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* 11. Office Structure and Layout:

How many examination rooms do you have?

How many employess do you have?

What is your office managers name?

Is your office computerized?

Do you have an area where you can hold health seminars?

Do you have a computerized mailing list of past and present patients?

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* 12. Your Master Plan and Vision:

a. What are your short-term goals for your practice (things you'd like to achieve in the next 6 months)

- Monthly Gross Revenue:

- Hours Working In Practice:

- Lifestyle:

- Other:

b. What are your long-term goals for your practice (things you'd like to achieve in the next 1-5 years)

- Monthly Gross Revenue:

- Hours Working In Practice:

- Lifestyle:

- Other:

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* 13. Personal Goals - Reflections:

a. Are you excited to get to your office and start each day no matter what you have to do?

b. Are you satisfied with your present income level or are you working more but making less?

c. Is your marketing consistently generating a steady flow of high profit patients who gladly pay your fees at any price and eagerly refer their family and friends?

d. Can you honestly say that you are achieving exactly what you truly want or are you left with a feeling that there is so much more that you can attain?

e. Do you feel that you are as successful as you can be?

f. Do you have the practice and lifestyle you’ve always desired?

g. What is it that you dislike about your practice?

h. What is it that you like about your practice?

i. Tell me what your patients like most about your practice?

j. What do your patients dislike about your practice?

k. What are your strong points?

l. What are your weak points?

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* 14. Personal Goals - Desires (What Prevents You From Being As Successful As You Can Be?):

a. A lack of focus?

b. Not having a clear vision, plan, goal, target or blueprint for success?

c. Spending time and energy on seemingly “urgent” activities instead of what is truly important?

d. Procrastination or constantly “getting ready” to “get ready”?

e. Clutter and the lack of organization?

f. Limiting beliefs about our ability to succeed – often unconscious?

g. A lack of confidence in selling cash based treatment plans?

h. Giving in to the negative influences and people around you?

i. Expecting to get rich quick without providing value?

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* 15. What Is Your Mission Statement?

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* 16. Please Tell Me As If I Were A Potential Patient, Why Should I Choose You Over Every Other Choice I Have (e.g. your competiton or those companies that sell products on the internet) and Why Now?

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* 17. What Procedures Services and Products Do You Presently Offer or Will Be Offering In The Future?

	Presently Offering	Will Be Offering	Won't Be Offering	Need More Information
Microdermabrasion	Microdermabrasion Presently Offering	Microdermabrasion Will Be Offering	Microdermabrasion Won't Be Offering	Microdermabrasion Need More Information
Chemical Peels	Chemical Peels Presently Offering	Chemical Peels Will Be Offering	Chemical Peels Won't Be Offering	Chemical Peels Need More Information
Botox	Botox Presently Offering	Botox Will Be Offering	Botox Won't Be Offering	Botox Need More Information
Restylane	Restylane Presently Offering	Restylane Will Be Offering	Restylane Won't Be Offering	Restylane Need More Information
Juvederm	Juvederm Presently Offering	Juvederm Will Be Offering	Juvederm Won't Be Offering	Juvederm Need More Information
Fraxel	Fraxel Presently Offering	Fraxel Will Be Offering	Fraxel Won't Be Offering	Fraxel Need More Information
Thermage	Thermage Presently Offering	Thermage Will Be Offering	Thermage Won't Be Offering	Thermage Need More Information
Sculptra	Sculptra Presently Offering	Sculptra Will Be Offering	Sculptra Won't Be Offering	Sculptra Need More Information
Cosmeceuticals	Cosmeceuticals Presently Offering	Cosmeceuticals Will Be Offering	Cosmeceuticals Won't Be Offering	Cosmeceuticals Need More Information
Neutriceuticals	Neutriceuticals Presently Offering	Neutriceuticals Will Be Offering	Neutriceuticals Won't Be Offering	Neutriceuticals Need More Information
Computerized Complexion Analysis (e.g. VISIA)	Computerized Complexion Analysis (e.g. VISIA) Presently Offering	Computerized Complexion Analysis (e.g. VISIA) Will Be Offering	Computerized Complexion Analysis (e.g. VISIA) Won't Be Offering	Computerized Complexion Analysis (e.g. VISIA) Need More Information
IPL Hair Removal	IPL Hair Removal Presently Offering	IPL Hair Removal Will Be Offering	IPL Hair Removal Won't Be Offering	IPL Hair Removal Need More Information
Laser Hair Removal	Laser Hair Removal Presently Offering	Laser Hair Removal Will Be Offering	Laser Hair Removal Won't Be Offering	Laser Hair Removal Need More Information
Photo Facials	Photo Facials Presently Offering	Photo Facials Will Be Offering	Photo Facials Won't Be Offering	Photo Facials Need More Information
Sclerotherapy	Sclerotherapy Presently Offering	Sclerotherapy Will Be Offering	Sclerotherapy Won't Be Offering	Sclerotherapy Need More Information
Laser Vein Removal	Laser Vein Removal Presently Offering	Laser Vein Removal Will Be Offering	Laser Vein Removal Won't Be Offering	Laser Vein Removal Need More Information
Tatoo Removal	Tatoo Removal Presently Offering	Tatoo Removal Will Be Offering	Tatoo Removal Won't Be Offering	Tatoo Removal Need More Information
Mesotherapy	Mesotherapy Presently Offering	Mesotherapy Will Be Offering	Mesotherapy Won't Be Offering	Mesotherapy Need More Information
LipoDissolve	LipoDissolve Presently Offering	LipoDissolve Will Be Offering	LipoDissolve Won't Be Offering	LipoDissolve Need More Information
Weight-Loss Programs	Weight-Loss Programs Presently Offering	Weight-Loss Programs Will Be Offering	Weight-Loss Programs Won't Be Offering	Weight-Loss Programs Need More Information
Acne Programs	Acne Programs Presently Offering	Acne Programs Will Be Offering	Acne Programs Won't Be Offering	Acne Programs Need More Information
Hormone Therapy - women	Hormone Therapy - women Presently Offering	Hormone Therapy - women Will Be Offering	Hormone Therapy - women Won't Be Offering	Hormone Therapy - women Need More Information
Hormone Therapy - men	Hormone Therapy - men Presently Offering	Hormone Therapy - men Will Be Offering	Hormone Therapy - men Won't Be Offering	Hormone Therapy - men Need More Information
Age Spot Removal	Age Spot Removal Presently Offering	Age Spot Removal Will Be Offering	Age Spot Removal Won't Be Offering	Age Spot Removal Need More Information
Massage Therapy	Massage Therapy Presently Offering	Massage Therapy Will Be Offering	Massage Therapy Won't Be Offering	Massage Therapy Need More Information
Pain Relief Services	Pain Relief Services Presently Offering	Pain Relief Services Will Be Offering	Pain Relief Services Won't Be Offering	Pain Relief Services Need More Information
a. Trigger Point Therapy	a. Trigger Point Therapy Presently Offering	a. Trigger Point Therapy Will Be Offering	a. Trigger Point Therapy Won't Be Offering	a. Trigger Point Therapy Need More Information
b. Spinal Joint Injections	b. Spinal Joint Injections Presently Offering	b. Spinal Joint Injections Will Be Offering	b. Spinal Joint Injections Won't Be Offering	b. Spinal Joint Injections Need More Information
c. Physical Therapy	c. Physical Therapy Presently Offering	c. Physical Therapy Will Be Offering	c. Physical Therapy Won't Be Offering	c. Physical Therapy Need More Information
d. Spinal Decompression	d. Spinal Decompression Presently Offering	d. Spinal Decompression Will Be Offering	d. Spinal Decompression Won't Be Offering	d. Spinal Decompression Need More Information
e. Computerized Motion Analysis	e. Computerized Motion Analysis Presently Offering	e. Computerized Motion Analysis Will Be Offering	e. Computerized Motion Analysis Won't Be Offering	e. Computerized Motion Analysis Need More Information
f. BioFreeze Pain Gel	f. BioFreeze Pain Gel Presently Offering	f. BioFreeze Pain Gel Will Be Offering	f. BioFreeze Pain Gel Won't Be Offering	f. BioFreeze Pain Gel Need More Information

Please List Additional Services or Comments

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* 18. General Marketing Questions:

Do you have a staff person who does your marketing?

How many new patients do you see a month?

How many new patients a month do you get from patients?

How many referrals a month do you get from other doctors?

How many referrals a month do you get from surrounding business?

What is your greatest source of new referrals?

How do you presently market for new patients?

How do you market to your existing patients?

Do you offer a free consultation?

Do you offer discounts to new patients?

Do your offer discounts to returning patients?

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* 19. Statistics:

a. On average, how much do you spend a month on marketing?

b. On average, how many new patients do you see per month?

b. What does the average person spend on their first visit? (Front End Business)

c. What does the average person spend with you in 12 months? (Lifetime Value)

e. On average, how many patient visits do you see per week?

f. On average, how many patients become inactive per month?

g. On average, how many of your inactive patients do you reactivate per month?

h. What does the average new patient spend on their first visit? (Front End Business)

i. What does the average new patient spend with you across 12 months? (Lifetime Value)

j. What is your average monthly gross collections?

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* 20. Communications:

a. Number of daily publications in your area?

b. Number of weekly publication in your area?

- Of these publications, how many are free (e.g. penny saver)?

- How many are paid publications (e.g. daily paper)

c. Is there a talk radio station most people listen to?

d. Are there local cable tv stations that post community events?

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* 21. Please Tell Me Which of the Internal Marketing Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

	Very Effective	Effective	Neutral	Ineffective	Very Ineffective	Haven't Tried This Strategy
1. Loyalty Rewards Program or Frequent Buyer Program	1. Loyalty Rewards Program or Frequent Buyer Program Very Effective	1. Loyalty Rewards Program or Frequent Buyer Program Effective	1. Loyalty Rewards Program or Frequent Buyer Program Neutral	1. Loyalty Rewards Program or Frequent Buyer Program Ineffective	1. Loyalty Rewards Program or Frequent Buyer Program Very Ineffective	1. Loyalty Rewards Program or Frequent Buyer Program Haven't Tried This Strategy
a. Points towards products and services	a. Points towards products and services Very Effective	a. Points towards products and services Effective	a. Points towards products and services Neutral	a. Points towards products and services Ineffective	a. Points towards products and services Very Ineffective	a. Points towards products and services Haven't Tried This Strategy
b. Special pricing for maintenance plans	b. Special pricing for maintenance plans Very Effective	b. Special pricing for maintenance plans Effective	b. Special pricing for maintenance plans Neutral	b. Special pricing for maintenance plans Ineffective	b. Special pricing for maintenance plans Very Ineffective	b. Special pricing for maintenance plans Haven't Tried This Strategy
c. Quarterly or end of year bonuses and gifts	c. Quarterly or end of year bonuses and gifts Very Effective	c. Quarterly or end of year bonuses and gifts Effective	c. Quarterly or end of year bonuses and gifts Neutral	c. Quarterly or end of year bonuses and gifts Ineffective	c. Quarterly or end of year bonuses and gifts Very Ineffective	c. Quarterly or end of year bonuses and gifts Haven't Tried This Strategy
2. Preferred Patient Program – incentive for existing medical patients who try new services	2. Preferred Patient Program – incentive for existing medical patients who try new services Very Effective	2. Preferred Patient Program – incentive for existing medical patients who try new services Effective	2. Preferred Patient Program – incentive for existing medical patients who try new services Neutral	2. Preferred Patient Program – incentive for existing medical patients who try new services Ineffective	2. Preferred Patient Program – incentive for existing medical patients who try new services Very Ineffective	2. Preferred Patient Program – incentive for existing medical patients who try new services Haven't Tried This Strategy
3. Refer a Friend Program (Patients)	3. Refer a Friend Program (Patients) Very Effective	3. Refer a Friend Program (Patients) Effective	3. Refer a Friend Program (Patients) Neutral	3. Refer a Friend Program (Patients) Ineffective	3. Refer a Friend Program (Patients) Very Ineffective	3. Refer a Friend Program (Patients) Haven't Tried This Strategy
4. Refer a Friend Program (Staff)	4. Refer a Friend Program (Staff) Very Effective	4. Refer a Friend Program (Staff) Effective	4. Refer a Friend Program (Staff) Neutral	4. Refer a Friend Program (Staff) Ineffective	4. Refer a Friend Program (Staff) Very Ineffective	4. Refer a Friend Program (Staff) Haven't Tried This Strategy
5. Happy Birthday Program	5. Happy Birthday Program Very Effective	5. Happy Birthday Program Effective	5. Happy Birthday Program Neutral	5. Happy Birthday Program Ineffective	5. Happy Birthday Program Very Ineffective	5. Happy Birthday Program Haven't Tried This Strategy
6. Added Value Savings Day	6. Added Value Savings Day Very Effective	6. Added Value Savings Day Effective	6. Added Value Savings Day Neutral	6. Added Value Savings Day Ineffective	6. Added Value Savings Day Very Ineffective	6. Added Value Savings Day Haven't Tried This Strategy
7. Patient of the Month Program	7. Patient of the Month Program Very Effective	7. Patient of the Month Program Effective	7. Patient of the Month Program Neutral	7. Patient of the Month Program Ineffective	7. Patient of the Month Program Very Ineffective	7. Patient of the Month Program Haven't Tried This Strategy

Comments:

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* 22. Please Tell Me Which of the Stay In Touch Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

	Very Effective	Effective	Neutral	Ineffective	Very Ineffective	Haven't Tried This Strategy
1. Patient Appreciation Events	1. Patient Appreciation Events Very Effective	1. Patient Appreciation Events Effective	1. Patient Appreciation Events Neutral	1. Patient Appreciation Events Ineffective	1. Patient Appreciation Events Very Ineffective	1. Patient Appreciation Events Haven't Tried This Strategy
2. Community Events	2. Community Events Very Effective	2. Community Events Effective	2. Community Events Neutral	2. Community Events Ineffective	2. Community Events Very Ineffective	2. Community Events Haven't Tried This Strategy
3. Reactivation Campaigns	3. Reactivation Campaigns Very Effective	3. Reactivation Campaigns Effective	3. Reactivation Campaigns Neutral	3. Reactivation Campaigns Ineffective	3. Reactivation Campaigns Very Ineffective	3. Reactivation Campaigns Haven't Tried This Strategy
4. Seasonal or Monthly Specials	4. Seasonal or Monthly Specials Very Effective	4. Seasonal or Monthly Specials Effective	4. Seasonal or Monthly Specials Neutral	4. Seasonal or Monthly Specials Ineffective	4. Seasonal or Monthly Specials Very Ineffective	4. Seasonal or Monthly Specials Haven't Tried This Strategy
5. Monthly Newsletters	5. Monthly Newsletters Very Effective	5. Monthly Newsletters Effective	5. Monthly Newsletters Neutral	5. Monthly Newsletters Ineffective	5. Monthly Newsletters Very Ineffective	5. Monthly Newsletters Haven't Tried This Strategy
6. Monthly Workshops	6. Monthly Workshops Very Effective	6. Monthly Workshops Effective	6. Monthly Workshops Neutral	6. Monthly Workshops Ineffective	6. Monthly Workshops Very Ineffective	6. Monthly Workshops Haven't Tried This Strategy
7. Periodic Surveys	7. Periodic Surveys Very Effective	7. Periodic Surveys Effective	7. Periodic Surveys Neutral	7. Periodic Surveys Ineffective	7. Periodic Surveys Very Ineffective	7. Periodic Surveys Haven't Tried This Strategy
8. Call To Your Patients	8. Call To Your Patients Very Effective	8. Call To Your Patients Effective	8. Call To Your Patients Neutral	8. Call To Your Patients Ineffective	8. Call To Your Patients Very Ineffective	8. Call To Your Patients Haven't Tried This Strategy
9. Email Communications	9. Email Communications Very Effective	9. Email Communications Effective	9. Email Communications Neutral	9. Email Communications Ineffective	9. Email Communications Very Ineffective	9. Email Communications Haven't Tried This Strategy

Comments:

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* 23. Please Tell Me Which of the External Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

	Very Effective	Effective	Neutral	Ineffective	Very Ineffective	Haven't Tried This Strategy
1. Newspaper Ads,	1. Newspaper Ads, Very Effective	1. Newspaper Ads, Effective	1. Newspaper Ads, Neutral	1. Newspaper Ads, Ineffective	1. Newspaper Ads, Very Ineffective	1. Newspaper Ads, Haven't Tried This Strategy
2. TV	2. TV Very Effective	2. TV Effective	2. TV Neutral	2. TV Ineffective	2. TV Very Ineffective	2. TV Haven't Tried This Strategy
4. Radio	4. Radio Very Effective	4. Radio Effective	4. Radio Neutral	4. Radio Ineffective	4. Radio Very Ineffective	4. Radio Haven't Tried This Strategy
5. Mailers	5. Mailers Very Effective	5. Mailers Effective	5. Mailers Neutral	5. Mailers Ineffective	5. Mailers Very Ineffective	5. Mailers Haven't Tried This Strategy
a. direct mail	a. direct mail Very Effective	a. direct mail Effective	a. direct mail Neutral	a. direct mail Ineffective	a. direct mail Very Ineffective	a. direct mail Haven't Tried This Strategy
b. new mover campaigns	b. new mover campaigns Very Effective	b. new mover campaigns Effective	b. new mover campaigns Neutral	b. new mover campaigns Ineffective	b. new mover campaigns Very Ineffective	b. new mover campaigns Haven't Tried This Strategy
6. Publicity	6. Publicity Very Effective	6. Publicity Effective	6. Publicity Neutral	6. Publicity Ineffective	6. Publicity Very Ineffective	6. Publicity Haven't Tried This Strategy
7. Joint Venture Marketing – Develop Relationships	7. Joint Venture Marketing – Develop Relationships Very Effective	7. Joint Venture Marketing – Develop Relationships Effective	7. Joint Venture Marketing – Develop Relationships Neutral	7. Joint Venture Marketing – Develop Relationships Ineffective	7. Joint Venture Marketing – Develop Relationships Very Ineffective	7. Joint Venture Marketing – Develop Relationships Haven't Tried This Strategy
8. Special Community Events – Yours and Others	8. Special Community Events – Yours and Others Very Effective	8. Special Community Events – Yours and Others Effective	8. Special Community Events – Yours and Others Neutral	8. Special Community Events – Yours and Others Ineffective	8. Special Community Events – Yours and Others Very Ineffective	8. Special Community Events – Yours and Others Haven't Tried This Strategy
a. Seminars, Workshops, Talks	a. Seminars, Workshops, Talks Very Effective	a. Seminars, Workshops, Talks Effective	a. Seminars, Workshops, Talks Neutral	a. Seminars, Workshops, Talks Ineffective	a. Seminars, Workshops, Talks Very Ineffective	a. Seminars, Workshops, Talks Haven't Tried This Strategy
b. Fund Raisers - e.g. Food Drive	b. Fund Raisers - e.g. Food Drive Very Effective	b. Fund Raisers - e.g. Food Drive Effective	b. Fund Raisers - e.g. Food Drive Neutral	b. Fund Raisers - e.g. Food Drive Ineffective	b. Fund Raisers - e.g. Food Drive Very Ineffective	b. Fund Raisers - e.g. Food Drive Haven't Tried This Strategy

Comments:

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* 24. Please answer the following questions by listing in their order of priority the areas you think your practice needs help (with number 1 being the highest priority, 5 being the lowest priority).

Time management skills

Staff development and management techniques

Consistently marketing for high quality patients

Getting a better response from your advertising

Organizing a marketing campaign

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* 25. What areas of your practice are you looking for help with (e.g. staff training, new patient acquisition)?

Thank you for completing this Practice Evaluation Questionnaire.
In the next day or so, you will receive a call from my office to schedule your one-on-one “Get Ready For Success” phone consultation with Dr. Nelligar.

For up-to-date health and wellness information go to www.BodyFocus.me

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* 26. Select Which of Our Services You Are Interested In?

Website Development and Logo Branding

Guaranteed New Patient Program for Dentists

a. Lead Generation Search Engine Marketing and Advertising

b. Lost Patient Recovery System (reactivation of inactive patients)

c. Done for You Email, Mobile and SMS Marketing

d. Patient Loyalty Reward Programs

e. Reputation Management for Dentists - helping you create a 5 star reputation with your patients online

S.T.A.R.S. Success Staff Training Program™ for Dental Practices

A. Front office telephone scripting and monitoring

B. Sales call training

C. Practice coordination

D. Direct Mail Marketing

E. Doctorpreneur™ Academy with Dr. Nelligar (one-on-one coaching program)

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* 1. Contact Information

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* 2. Credentials

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* 3. Contact Information

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* 4. Do you have a website?

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* 5. If yes, what is the address of your website (e.g. www.domainanme.com)

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* 6. Is a company optimizing your website regularly for keywords relating to your products and services so your website can be found on Google, Bing and Yahoo?

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* 7. If no one is presently optimizing your website, is this a new service you would be interested in help to get more business?

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* 8. Provide us with at least two competitor websites in your area

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* 9. Demographics:

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* 10. General Practice Information:

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* 11. Office Structure and Layout:

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* 12. Your Master Plan and Vision:

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* 13. Personal Goals - Reflections:

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* 14. Personal Goals - Desires (What Prevents You From Being As Successful As You Can Be?):

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* 15. What Is Your Mission Statement?

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* 16. Please Tell Me As If I Were A Potential Patient, Why Should I Choose You Over Every Other Choice I Have (e.g. your competiton or those companies that sell products on the internet) and Why Now?

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* 17. What Procedures Services and Products Do You Presently Offer or Will Be Offering In The Future?

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* 18. General Marketing Questions:

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* 19. Statistics:

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* 20. Communications:

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* 21. Please Tell Me Which of the Internal Marketing Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

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* 22. Please Tell Me Which of the Stay In Touch Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

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* 23. Please Tell Me Which of the External Strategies Listed Below You Have Tried and In Your Opinion How Effective They Were:

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* 24. Please answer the following questions by listing in their order of priority the areas you think your practice needs help (with number 1 being the highest priority, 5 being the lowest priority).

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* 25. What areas of your practice are you looking for help with (e.g. staff training, new patient acquisition)?

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* 26. Select Which of Our Services You Are Interested In?

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* 27. If you could ask Dr. Nelligar 3 questions relating to growing your business, what would they be?