INTERNAL ONLY - Patient Accelerator Program Contract SUBMISSION
Practice Information
Please enter all of the practice information for onboarding and for the contract that will be email to the client.
Legal Business Name
*
What is Your Practice Name?
*
Legal Name of Signee
*
First
Last
Title
*
Primary Email Address
*
Mobile Phone Number
*
Practice Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Time Zone
*
Atlantic Time (AT)
Eastern Time (ET)
Central Time (CT)
Mountain Time (MT)
Pacific Time (PT)
What do locals call the area your practice is located?
What is your practice website address?
In order to tailor your marketing to your practice, do you give TRBO ADvance permission to use videos/images from your website in the marketing?
Yes
No
Hidden
What is your Facebook Page URL?
Practice Classification
*
Plastic Surgery
Medical Spa
Dermatology
Vein Center
OBGYN
General Medicine
Campaign Information
Did you Lease or Purchase Your Device?
*
Purchase
Lease
Program Selection
*
Enlighten – PicoGenesis/Skin Rejuvenation
Enlighten – Tattoo Removal
Excel HR
Excel V+ Laser Genesis
Excel V+ Vascular
Secret PRO / Fraxis PRO
Juliet
Secret RF Microneedling
truBody
truSculpt iD
truSculpt fleX
Xeo Laser Genesis
Xeo Laser Hair Removal
Additional devices not covered by PAP, if applicable
Who will be contacting your leads?
*
First
Last
Leads Point of Contact Phone Number
*
Leads Point of Contact Email
*
What other email address(es) should we send your leads to?
Geographic Targeting for Ads – Distance from Practice
*
10 miles
15 miles
25 miles
50 miles
50+ miles
Cities and zip codes to include/emphasize in marketing
Do You Charge for Consultations?
*
YES
NO
Please upload your logo.
Drop files here or
Select files
Accepted file types: png, pdf, eps, ai, psd, jpg, gif, Max. file size: 50 MB, Max. files: 4.
If you do not upload your logo here, we will attempt to pull it off of your website.
Additional Notes, Promotions or Specials we should promote?
Invoice Number