INTERNAL USE: Cutera Patient Accelerator Program Intake

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 Country
Time Zone*
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*
Cities and zip codes to include/emphasize in marketing
Do You Charge for Consultations?*
- YES
- NO
Please upload your logo.
Drop files here or

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

INTERNAL ONLY - Patient Accelerator Program Contract SUBMISSION

Practice Information

Campaign Information