New Client Intake — The Implant Initiative

Practice info

Basic contact details so we know who we're working with.

Primary contact

First name *

Last name *

Practice name *

Email address *

Phone number *

Practice address

Street address *

Suite, unit, or floor (optional)

City *

State *

ZIP / Postal code *

Practice website

Is your mailing address the same as your physical address? *

Yes — same as physical No — different mailing address

Mailing address

Street address

Suite, unit, or floor (optional)

City

State

ZIP / Postal code

Treatment coordinator

Do you have a dedicated TC? *

Yes, dedicated full-time TC Yes, TC who also handles other roles No, front desk handles it No TC at all

TC contact info

TC full name

Direct email

Direct phone / ext

Years in the TC role

Key contacts

Contact 1

Full name

Role

Email

Phone / ext

Please complete the required fields above.

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Implant pipeline

Estimates are fine — we'll refine these numbers together on our first call.

Experience

How long have you been placing implants? *

Less than 1 year 1–3 years 3–7 years 7+ years

Pipeline numbers

Cases placed / month5

160+

Implant leads / month30

0300+

Average case value$16,000

$3k$45k+

Consult show rate60%

10%100%

Lead to booked consult22%

5%60%

Treatment acceptance22%

5%65%

Financing options

Which patient financing options does the practice currently offer? Select all that apply.

Sunbit

CareCredit

Cherry

Alphaeon

Proceed Finance

LendingClub

GreenSky

Ally

In-house financing

None

Other providers (optional — add up to 3)

Please complete the required fields above.

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Marketing & team

Where are your leads coming from, and who's handling them?

Lead sources

Current lead sources — select all that apply

Google Ads

Facebook / Instagram

SEO / Organic

Referrals

Direct mail

Radio / TV

Word of mouth

None yet

Monthly ad spend$3,000

$0$30k+

Agency

Are you currently working with a marketing agency?

Yes No Just left one

Systems

Practice management software (PMS)

Can you export a list of unscheduled implant tx plans — or would we need to have someone go compile that list manually?

Yes, I can export it from our PMS No, someone would need to compile it manually Not sure, need to check

Please complete the required fields above.

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Goals & context

Last step. Help us understand what success looks like in the next 90 days.

Priorities

90-day goals — select all that apply *

Close more cases from existing leads

Increase consult show rates

Improve TC conversion

Get more leads

Build a KPI dashboard

Scale to multiple locations

Diagnosis

Where do you think your biggest leak is?

Lead follow-up / speed to respond Booking rate — leads not converting to consults Consult show rate Treatment acceptance / TC performance Not sure — that's why I'm here

Target revenue

Annual implant revenue goal,000,000

00kM+

How you found us

How did you hear about The Implant Initiative?

Anything else

Notes for our first call

Please complete the required fields above.

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Tell us about your practice.

Practice info

Implant pipeline

Marketing & team

Goals & context

Intake received.