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AI Concierge Intake Form

Please fill out the form below so that I can get started crafting your AI Concierge for your practice. If you run into any issues or have any questions please feel free to contact me.

Practice Information

Practice Name(Required)

Practice Website(Required)

Location(Required)

City State

Type of Practice(Required)

Other

Primary Contact

Name(Required)

First Last

Role at the Practice(Required)

Email(Required)

Phone

Current Systems & Workflow

Do you currently use any of the following?(Required)

EMR / EHR (e.g., Nextech, ModMed)

Online Booking

Patient Portal

CRM / Lead Tracking

AI tools (e.g., ChatGPT, Doximity)

Other

Other

What is your biggest bottleneck in your front-office workflow?(Required)

AI Goals & Interests

What would you most like AI to help with?(Required)

Automating patient inquiries

Reducing front-desk workload

Improving response time

Scheduling & reminders

Insurance/pre-qual questions

Something else

Please describe

If you could wave a magic wand and fix one thing with automation, what would it be?(Required)

Timeline & Future Intent

Do you have a timeline in mind?(Required)

ASAP

Within 30 days

Within 3 months

Just exploring

Are you interested in ongoing strategy or just a one-time setup?(Required)

One-time setup only

Occasional check-ins and updates

Monthly or long-term support

Not sure yet

Which Concierge package are you interested in?(Required)

🧰 Standard Concierge – $300 (basic setup + handoff)

🚀 Premium Concierge – $500 (setup + full integration + support)

🤔 Not sure yet – help me decide

What’s your current level of comfort with AI tools like ChatGPT or Google Bard?

I use them regularly

I’ve tried them, but need help

I’m brand new to all this

I don’t know what’s possible

What kind of help are you looking for?

Build a specific tool or automation

Make my current system work better

Integrate AI into my website, emails, or forms

I don’t know what’s possible — just show me what’s out there

Do you have someone on your team who can manage the AI system after it’s built?

Yes, I (or my team) can take over

I’d prefer ongoing help or check-ins

Not sure yet

Standard Package is Likely a Good Fit

Based on your answers, the Standard package should cover your needs. We’ll confirm this before we begin.

You Might Benefit From the Premium Package

Looks like you want deeper integration or guidance. The Premium package sounds like a match.

Thanks! We’ll Help You Decide

Your answers suggest a custom recommendation would be best. We’ll follow up with next steps.

We’ll be in touch to help you decide the best option for your needs.

Selected Package

Standard – $300

Premium – $500

Total

Payment Method

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

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About
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