Form

Practice Information
*required fields
Conceptus Account Number
Primary Doctor Name*
Additional Doctor(s)
Practice Name
Main Location (address, city, state and zip code)*
Additional Locations (address, city, state and zip code)
Time Zone
Phone Number (include area code)*
Doctor cell or backline (include area code)
Doctor Email
Practice Contact (Name, Title, Phone Number and Email)*
Website
Who will prepare Essure materials? (Name, Phone Number and Email)*
Other Information
Name of your Conceptus rep and/or ED manager*
Do you currently offer Essure in-office?

Yes No
Practice has completed advanced certification for EAP status

Yes No
Do you accept Medicaid for Essure?

Yes No
Your Essure Account
After receipt of this form, and approvals from Conceptus, your PatientBuilder account will be set up within two (2) business days.
Choose one*

Use basic set up (no logo, just typeset information) I have a logo and will email it to customersupport@patientbuilder.com. Use photograph instead of logo. Email a high-res photo to customersupport@patientbuilder.com If the logo is too poor to reproduce, PatientBuilder will default to typeset information.
Essure Materials
Practice Plans to Use*

Co-op Dollars Essure Postcard Campaign Essure Print Ads Essure Confirmation test reminder card/envelope Essure Appointment Card
Maximum budget for practice's share of postcard campaign

$1,000-$2,000 $2,000-$3,000 $3,000-$4,000 $4,000-$5,000
Maximum budget for practice's share of print ad campaign

$1,000-$2,000 $2,000-$3,000 $3,000-$4,000 $4,000-$5,000
Media Information
All Essure advertising is arranged by PatientBuilder's Media Team. Please let us know your plans and PB will prepare a media proposal for your Essure campaign, and also can incorporate your postcard campaign. (Allow 7 business days for proposal preparation.)
Allow 2 weeks after practice's approval of media proposal for placement to begin (1 month for magazine placement).
I am interested in

Newspaper Ads Magazine Ads Advertorials (article + ad combination)
List specific publication(s) and any current contact
Would you like PB to recommend other ad options?

Yes No
Online Help
When your PatientBuilder account is ready, you will be emailed your account logins and help sheets to get you started. We are happy to work online with you to prepare your Essure materials...schedule now or call Customer Support at 417-447-5050.
Select a preferred time and an alternate, Monday-Friday, 9am-4pm Central time (allow 30-45 minutes). You will receive an email confirming the appointment.
Preferred Online Appointment
Day/Date
- Month - Day Year
at
/ Hour Minutes
Time between 8am-4pm Central
Alternate Online Appointment
Day/Date
- Month - Day Year
at
/ Hour Minutes
Time between 8am-4pm Central
Additional Comments
Form submitted by*
Date*
- Month - Day Year
at
/ Hour Minutes
Should be Empty:

Practice Information

Other Information

Your Essure Account

Essure Materials

Media Information

Online Help