Your name *
Department Name *
Approving director *
Please include anyone who will need to review the materials before approval.
Today's date *
Example Format: MM/DD/YYYY
Requested completion date?
Example Format: MM/DD/YYYY
Please note - projects that flow through the Marketing department are assigned pre-set timelines. Your strategist will discuss timelines with you.
What are you trying to communicate? *
Provide the following information: what is the service, is it a new or existing service, how does a patient access this service (self-refer, provider referral, etc.)?
What do you want to accomplish? *
Grow volume, create awareness, gain referrals, etc. what are you trying to achieve with this marketing effort?
What is the benefit of this service to the patient? *
New service option, won't have to travel for this service, cost effective, relieves symptoms?
What does the target look like? *
Current symptoms, diagnosis, etc.
GL and billing account *
Have a budget? If yes, how much? *
Contact information *
Please provide he current phone number, fax number, address and department name.
Competition *
Who is our competition in the market?
Access *
What is current access to the service like? How many days out for first available appointment?
Delivery information *
If delivery address for materials is different than address listed above.
Other information you'd like us to know? *
leave this field blank to prove your humanity