1. Which of the following changes in your practice or healthcare organization most accurately reflect your goal? (Check all that apply) I would like to…
   
   Spend a greater percentage of time on cases which take advantage of my (our) specialized expertise
   
   Enhance our reputation
   
   Spend more time treating, not administrating
   
   Win more doctor (or other professional) referrals
   
   Attract higher paying cases
   
   Attract elective and/or cash cases
   
   Increase the number of patients we attract
   
   Target specific insurances
   
   Reduce my reliance on low paying insurances
   
   Reduce our over-reliance on a small number of referral sources
   
   Create more volume to feed new partners, associates or extenders
   
   Make sure our new location is successful
   
   Answer aggressive competition which has emerged in my area
   
   Build up a business I recently joined or purchased
   
   Take our business to the next level
   
   Enable the organization to support charitable causes or provide community services
   
   Take more time off of work to spend with my family and/or other interests
   
   Become recognized as a leader in my field
2. How much would you like to increase your profits over the next 12 months?
   Over 100% 50 to 100% 25 to 50% Less then 25%
3. How would you rate your current healthcare marketing program?
   Highly effective, I have plan and I am reaching my goals
   
   Somewhat effective, inconsistent efforts or results
   
   Not effective, no plan and no measurable results
   
   I do not have a marketing program

4. Are competitors actively marketing or advertising their practices or organizations?
   Yes
   
   Not Sure
   
   No

5. Are you a:
   Private Practice
   
   Hospital
   
   Manufacturer
   
   Pharmaceutical
   
   Distributor
   
   Entrepenuer
   
   Other

6. How many providers are in your business?
   
7. What has the revenue growth trend been for your business over the past 24 months?
   Up strongly: Annually 25% or more ahead of prior year
   
   Up somewhat: Annually 10% or more ahead of prior year
   
   Generally flat: No significant change from year to year
   
   Down somewhat: Down by about 10% from previous year
   
   Significantly down: Down by 25% from previous year
8. Approximately what were your annual gross revenues last year?
   Over $100 million $3 million to $99 million $1 million to $2.99 million $500.000 to $999.999 $250.000 to $ 499.999 $150.000 to $249.000 Less then $150.000
9. How much do you currently spend each month on marketing?
   
10. Finally, please feel free to elaborate on your situation, goals, etc., as much or little as you like.
    

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