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Campaign Details

Who will be contacting your leads?

Leads Point of Contact First Name *

Leads Point of Contact *

Leads Point of Contact Email *

Leads Point of Contact Phone Number *

What email address(es) should we send your leads to? *

Geographic Targeting for Ads - Distance from Practice *How far are patients willing to travel to you for the procedure(s) being targeted?

Do You Charge for Consultations? *

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*Please note that if you do not upload your logo we will attempt to pull it from your website.

Additional Notes, Promotions or Specials we should promote?Please be detailed so we can properly setup your campaign. Also note that a Special Offer or Discount will greatly increase your results. Be specific about treatment being discounted, how much the discount is, expiration of special offer (if applicable), and exclusions.

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