Fax or mail this application to:

Imagination @ Work, LLC

116 19th Avenue North, Unit 401

Jacksonville Beach, FL  32250

Phone:  904-372-0028

FAX:  904-372-0631

PATIENT CONTEST club

APPLICATION

Practice Name:                                                                                                                  

Doctor(s) Name:                                                                                                                

                                                                                                                                              

Business Address:                                                                                                             

                                                                                                                                              

Phone:                                                                              Fax:                                            

Web Site:                                                                                                                             

Email Address:                                                                                                                  

Marketing Contact for Office:                                                                                               

 

Which personality best describes your practice:

    ____Fun and upbeat                ____Professional yet lively             ____Professional & Peaceful

 

IMPORTANT DETAILS ABOUT YOUR MEMBERSHIP:

 

· Your patient contest information will be emailed to you every six weeks and you will receive a marketing/management tip at the first of each month.  Is there a different email address than the one listed above to send this to?                                                                                                                   

· It is very important that you do not delete any email from parenton@aol.com.  Make sure all your staff with access to your email are informed of this. 

· The Patient Contest Club, unlike The Imagination Club, is not an exclusive club since it deals only with internal marketing to your patients. 

· Within one-five business days of receiving your application, your membership will become active and you will receive your initial email from parenton@aol.com.

· Membership renewal is optional.  You will receive a renewal application at the end of your membership year. 

 

YES . . . make my staff’s job easier, sign us up for the Patient Contest Club today!

____$375 for One-Year Membership

____$700 for a Two-Year Membership

 

Payment Information:

o Check Enclosed                o Visa          o Mastercard

Credit Card #                                                                                                        

Expiration Date:                                               

 

                                                                                                                    

Doctor’s Signature                                                         Date