Offboarding Form Date Date Format: MM slash DD slash YYYY Client Name (practice name)*Client Number*Date Contract Signed*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Salesperson*-- Select --AmyScottVanceWendyInternal SalesDon't KnowSold Internally By*Brandon DiazDiego De Los ReyesDiego PerezGina DiGirolamoJana FeannyMagen TooleMayra RojasStephanie CeperoDate Marketing/Website Launched*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Days Between Signed Contract and LaunchMonths Between Launch and CancellationClient Success Manager*-- Select --Brandon DiazDiego De Los ReyesDiego PerezGina DiGirolamoJana FeannyMagen TooleMayra RojasStephanie CeperoPoint of Contact*DoctorOffice ManagerConsultantSpouseService*-- Select --DigitalMailCombinedDe NovoDigital Services* Google Ads Management Bing Ads Management Display Ads Management Facebook & Instagram Reputation Management Only Hosting Only SEO Only Mail Service* Mail A La Carte Whale Mail Monthly Billing Amount*Monthly Ad budget - Google & FacebookGoogle Adwords Avg CPCGoogle Adwords Avg CPLGoogle Adwords Average Monthly spendState Located-- Select --InternationalAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCity LocatedWebsite/landing page design satisfaction-- Select --123456789101 Dissatisfied - 10 Satisfied Average Zendesk Ticket Response : HH MM Start-up practice*YesNoFocus areaGeneral PracticeOrthodontistPediatricOther SpecialtyMulti Location*YesNoMarketing company they are going toCustomers of other Business units*YesNoI Don't KnowOther Business Units* Dental Entrepreneur Dental Fix Dental Whale Savings Network Florida Dental Repair Front Desk DDS Front Office Rocks Lean Dental Design Seminars Unlimitech Orca log-in frequencyCustomers reason for leaving*-- Select --Billing ErrorsClosing PracticeCSM CommunicationIn-House MarketingPerformanceSales Promises Not MetSelling PracticeWebsite CreationWebsite EditsPaste in any customer comments from tickets or emailsSubmitted By* First Last Email*
