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PatientBuilder.com Registration

Intuitive Surgical® is proud to partner with PatientBuilder to offer you a turn-key solution for your practice marketing needs. Please complete this registration form in its entirety; incomplete forms will delay your registration process. After receipt of this form, a quick-start PatientBuilder account will be set up within two (2) business days. This account will be fully active and include most information about your practice (artwork—logos, signatures, photos, maps—can be added as needed).

Crystal Mapp is your support for the da Vinci PatientBuilder program. Please fax or email forms, logos, and signatures to her attention. Phone: 417.447.5050 Fax: 417.447.4494 E-mail: davincisupport@patientbuilder.com

Please complete the following form to begin registration.

General Information

*required fields

Name of your Intuitive Surgical representative*

Primary Office Location (if you have more then one location list it at the end of the form)

Dr. Name*

Dr. Email

Practice Name*

Street Address*

City*

State*

Zip Code*

Time Zone

Phone Number* (please include area code)

Toll-free Phone Number

Fax

Website


Who in your practice should PatientBuilder contact?

Name*

Title

Phone Number* (please include area code)

Cell Phone or Back Line

Email Address*


Online Training

After your account is set up, your “key user/contact” should schedule an online tutorial to receive your logins, review the da Vinci Surgery 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.


Preferred date and time
Alternate date and time


Account Setup

Logos are required for almost all PatientBuilder materials. Please e-mail a color or black/white version of your logo in eps vector format to davincisupport@patientbuilder.com If you know your PMS ink color(s), please provide below.

PMS color

Be sure to include any variations that display the logo and contact information (address, phone, fax, website, etc.). Due to the layout constraints of certain PatientBuilder materials, it may be necessary to reformat your logo to fit the space available.

If your logo is in a format other than .eps, there will be an additional charge of $150 to convert it.

If you don’t have a logo, PatientBuilder can typeset your practice name, address and phone number in a professional font for free. Which statement best describes the situation for your practice logo:

I will e-mail the logo in .eps vector format to
I need my logo converted and I understand there is a $150 conversion charge
I need a logo, please create on for free by typesetting my practice name



Signature: Direct mail of letters requires the doctor’s signature. Which statement best describes the situation for the doctor’s signature:

I will email the signature as a .tiff scan to
I will fax my signature (signed large in black ink) to 417-447-4494



Direct mail of letters or postcards requires a mailing list. If you intend to provide your own patient mailing list for fulfillment of items ordered on PatientBuilder, you must sign a Business Associates Agreement to ensure HIPAA compliancy and upload the mailing list directly to the PatientBuilder server. Which statement best describes the situation for your mailing list:

I will upload our patient database to the PatientBuilder HIPAA compliant secure server—please call to assist me in converting the file to the required upload format (comma delimitated .csv or Excel file)
I don’t have a patient database so I will need PatientBuilder to help me generate a mailing list and I understand that this involves a list purchasing fee.


Other Information (if applicable)

Doctor(s) photograph - A high resolution photograph of the practice doctor(s), building, or staff is used on some postcards
I will email a high resolution photograph to
I do not plan to use this feature at this time



Practice location map - A map to your location can be used on some postcards and brochures
I will e-mail a non-copyrighted map to
I do not plan to use this feature at this time



Additional practice location

Practice Name

Street Address

City

State

Zip Code

Phone Number (please include area code)

Toll-free Phone Number

Fax

Website


I want to advertise (print, radio, TV) my practice.
Tell me more about the following services available from PatientBuilder

Media and Market Analysis Upon request, PatientBuilder will conduct a market and media analysis for your practice. This report will help you better understand marketing demographics and key media outlets, and will help you focus your external marketing campaign. The first part of the report is an overview of recommended media for your da Vinci targeted audience; the second part details a custom media “buy” proposal for your practice’s pre-determined dollar amount commitment for a da Vinci campaign. The fee for this service includes an analysis and report only; the media buy is billed separately. The cost for this is $300.00.
Yes, I want to know more



Media Buying Services If you elect to have PatientBuilder handle your media buy, your credit card will be charged monthly for the cost of purchasing media time/space, relative to the monthly allocation. However, you will be credited the $300.00 analysis cost toward your media buy.
Yes, I want to know more



PatientBuilder 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.

Publication/Station Contact name Phone Email



To confirm receipt and ensure immediate attention, please contact Crystal Mapp by phone: 417-447-5050 or email: after you have submitted this form.

*Form submitted by (name and title)

*I have read and agree with the user agreement


Terms and Conditions

Customer will have unlimited use and access to PatientBuilder for 12 months; accounts inactive for 3+ consecutive months may be deactivated. Annual renewal may be extended if approved by Intuitive Surgical.

Credit card information - Customer will pay online for any order costs using their credit card; no invoices will be sent, however Customer can review all orders in Order Status. Customer should submit confidential file credit card information to facilitate billing for requested graphics services or media placement assistance. Please submit your card type/name/account number/expiration to Customer Support (417.447.5050) or fax (417.447-4494).

If a credit card is declined, the Customer will be notified and have five (5) business days to provide PatientBuilder 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.

Production and Fulfillment - Many PatientBuilder 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. 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 will notify the Customer of the pending order and their responsibility.

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