Practice Information

*required fields

Dr. Name*

Conceptus Account Number*

Dr. Email

Practice Name*

Street Address*

City*

State*
(choose) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Puerto Rico Virgin Islands

Zip Code*

Time Zone
(Choose) Eastern Central Mountain Pacific Alaska Hawaii

Phone Number* (please include area code)

Toll-free Phone Number

Fax

Website

Practice’s Key User/Contact for Conceptus/PatientBuilder.com

Name*

Title

Phone Number* (please include area code)

Cell Phone or Back Line

Email Address*

General Information

Name of your Conceptus representative(s)*

PatientBuilder.com can provide media analysis research and/or media buys for print and radio/tv.
Do you plan to handle your own media arrangements?
Yes
No

If you currently have a media agreement or contract, please provide contact information for billing or placement involving PatientBuilder.com.

Online Training

After your account is set up, your “key user/contact” should schedule an online tutorial to receive your logins, review the Essure materials, and learn how to navigate the site. We will be happy to assist in preparing your initial order during your tutorial.

Book your tutorial now - Select a preferred time and an alternate, 8am-4pm Central time (Allow 30-45 minutes). You will receive an email confirming the appointment.

Your Quick-start Account

After receipt of this form, a quick-start PatientBuilder.com account will be set up within two (2) business days. This account will be fully active and include most information about your practice. In place of your practice logo, your practice name, address, and phone number (set in an appropriate font) will be used.

Fully Personalize Your Account

Logo* - E-mail a vector format (eps) of your practice logo to customersupport@patientbuilder.com (contact information may be adjusted to fit the available space on Essure materials.) If your logo is NOT in vector format (eps), PatientBuilder.com can recreate your graphic for $150. You must provide credit card information to PatientBuilder.com before this work will be done. For more information call Customer Support at 417.447.5050.
I have a logo in vector format and will email it to customersupport@patientbuilder.com
I have a logo, but need it recreated at $150; I will pre-provide credit card information
I do not have a logo

Doctor(s) photograph - A high resolution photograph of the practice doctor(s) may be used in place of a logo on some materials. You may email your photo to customersupport@patientbuilder.com, or upload it when creating your materials.

Terms and Conditions

Account setup is subject to approval by Conceptus. Customer will have unlimited use and access to PatientBuilder.com as long as activity is generated at least every 3 months. Inactive accounts may be deactivated, but can be extended if approved by Conceptus.

Payment Options-Customer will pay online via credit card for order costs. If customer elects to pay by check, the order will be held until payment is received by PatientBuilder.com. Additionally, PB can automatically process media expenses, discount pricing, and other approved charges if you submit your card type/name/account number/expiration to Customer Support (417-447-5050) or fax (417-887-2935). DO NOT EMAIL! All credit information is confidential and secure.

If a credit card is declined, the Customer will be notified and have five (5) business days to provide PatientBuilder.com with new card information. If this is not resolved, a final notification will go to the Customer and the Customer will no longer have access to PatientBuilder.com.

Mail list - If Customer intends to provide own mail list for fulfillment of items ordered on PatientBuilder.com, they must sign a Business Associates Agreement to ensure HIPAA compliancy and upload said mail list directly to the PatientBuilder.com server. Upload instructions are provided online

Production and Fulfillment - Many PatientBuilder.com materials are available at no cost and can be downloaded from Order Status. Allow ten (10) working days on items requiring production/fulfillment by PatientBuilder.com. If the Customer places an order prior to the expiration of their account, the Customer is responsible for the payments on any and all orders that require printing, generation of mailing lists, postage, or radio or television production that may be outstanding. In the event that this occurs, PatientBuilder.com will notify the Customer of the pending order and their responsibility.

*Form submitted by (name and title)

*I have read and agree with the user agreement

To confirm receipt and ensure immediate attention, please contact Susie Barr at 417-447-5050 or email sbarr@patientbuilder.com after you have submitted this form.