Digital Advertising Diagnostic Demo Request - USPI Service Line Strategy Group

Request a Demo - Cardiovascular Program

YOUR INFORMATION

Note: Your name, job title, and practice/organization information will be used for your name badge at the event.
Full Name*
First Name Last Name
Credentials
Job Title
Email Address*
Cell Phone Number
Practice or Organization Name:*
Address*
Street Address City State ZIP Code
Practice Phone Number*
Practice Billing Contact (if different from your name):
SUMMIT EVENTS

The following events are included in the cost of your registration.
I will be attending Reception and Dinner on March 21, 2018*
- Yes
- No
I will be attending the conference dinner party on March 22, 2018*
- Yes
- No
REGISTRATION FEE PAYMENT
- Send me an invoice
By selecting this option, you agree to be invoiced for the cost of the registration fee, $650 per person, by USPI’s OrthoLink at the practice address provided above. You are agreeing to pay the invoice as soon as possible within 30 days. Option to pay by credit card is available, and instructions for this will be provided on your invoice, or call 855.207.5230 to complete credit card payment today.
Completion of this form registers you for OrthoSummit events only. After hitting the button below, you will receive a confirmation with a link to book your hotel room nights for the event. OrthoSummit room rates are valid through February 20, 2018. To ensure availability, please make your hotel booking as soon as possible.
CAPTCHA

Fill out the form below to request your SEO Review Report. All fields are required.

SEO: REQUEST YOUR REVIEW REPORT
Your Name:*
Your Phone#:*
Your Email Address:*
PRACTICE INFO
Practice Name:*
Practice Website Address:
List full names of physicians in practice:
PROJECT CONTACT
Contact for this project (if different from above name):
Direct Line:
Email Address:
After hitting SUBMIT, you will receive a confirmation at the email address provided above. You will receive your SEO Review Report at the same email address within 7-10 business days after you hit submit.
By hitting SUBMIT, you agree to be invoiced for the cost of the SEO Review Report, $300, by USPI’s Physician Strategy Group within 72 hours. Upon completion of Review, should you decide to pursue repair recommendations, a separate bill would be generated for that work.*
- I agree
CAPTCHA

Fill out this form to sign up for 24/7 online scheduling. Items with an * are required

*Practice Name*
*Practice Address*
Street Address City State ZIP Code
*Practice Phone*
(###)-###-####
*List of Physicians in practice participating in Scheduling 24/7*
Practice Website Address
*Practice timezone*
*Practice Manager First Name*
*Practice Manager Last Name*
*Practice Manager email*
*I have read and accept the sign up agreement*
- *I agree
By submitting this form you have signed up for 24/7 scheduling, with the billing option you've selected.
CAPTCHA

Fill out this form to request a demo of Reputation.com

Your Name:*
Your Phone:*
Your Email:*
FACILITY OR PRACTICE INFO
Facility or Practice Name*
Facility or Practice Phone*
(###)-###-####
Facility or Practice Website Address
Are you interested in learning more about website development options through Service Line Strategy Group at USPI?
- yes
For Physicians Only. List of Physicians wanting to participate in Reputation.com*
PRODUCT DEMO CONTACT
Product Demo Contact (if different from above name):
Direct Line:
Email

Complete this form to register for the OrthoLink Summit

Full Name*
First Last
Credentials
Title
Practice Name
Practice Mailing Address
Street Address Address Line 2 City State ZIP Code
Office Phone Number*
Cell Phone Number
Email*
I will be attending reception and dinner on Wednesday, March 1, 2017*
- Yes
- No
I will be attending the conference dinner party at Charro Steak on Thursday, March 2, 2017*
- Yes
- No
Agreement*
- Yes
- No
By hitting SUBMIT below, you agree to be invoiced for the cost of the registration fee, $785 per person, by USPI’s OrthoLink at the practice address provided above. You are agreeing to pay the invoice as soon as possible within 30 days.
CAPTCHA

Fill out this form to request a demo of 24/7 online scheduling.

Fill out this form to request your consultation. A representative from impressLOCAL will be in touch soon to set up your meeting.

Practice Name*
Practice Address*
Street Address City State ZIP Code
Practice Phone*
(###)-###-####
Practice Website Address
Primary Contact's Direct Line (if different from Practice Phone)*
(###)-###-####
List of Physicians in practice participating in the Complimentary Consultation*
First Name of Primary Contact for Consultation*
Last Name of Primary Contact for Consultation*
Primary Contact for Consultation Email Address*
CAPTCHA

Fill out this form to sign up for Reputation.com. All field are required. Or call Erin Cox at 972.385.4277.

Your Name:*
Your Email:*
FACILITY OR PRACTICE INFO
Facility or Practice Name*
Facility or Practice Address*
Street Address City State ZIP Code
Facility or Practice Phone*
(###)-###-####
Facility or Practice Website Address
Are you interested in learning more about website development options through Service Line Strategy Group at USPI?
- yes
For Physicians Only. List of Physicians wanting to participate in Reputation.com*
SETUP & TRAINING CONTACT
Primary Contact for Setup & Training (if different from above name):
Direct Line:
Email
BILLING INFO
Primary Contact for Billing:*
- Check here if same as Setup & Training Contact
I understand I will be invoiced for the annual amount of $265 for facilities or $450 for physicians by Service Line Strategy Group at USPI. For physicians: I understand my invoice must be paid within 30 days or my Reputation.com account will be suspended. I can cancel any time after 60 days with a 30 day written notice sent to Service Line Strategy Group. For facilities: I understand the cost of my platform license will be paid through intercompany transfer by Service Line Strategy Group, unless I request differently.*
- I agree

SEO: REQUEST YOUR REVIEW REPORT