HMD Campaign Request Form

This form is to request market specific ads or campaigns outside of the corporate campaigns: One-off newspaper ad, local Chamber ad, etc.

My name is:*

Email*

Hospital / Clinic Name*

Please include the clinic or hospital name this will be associated with.

Is this in your Marketing Planner?*

If no, you must add to your planner prior to completing this request.

Yes

Include Link to Planner & Row #*

Please include marketing planner SmartSheet-specific link and note Row #.

What is the Request?*

Is it approval for a single ad placement or is it an entire campaign request? Be specific.

Date Submitted*

Date Needed in Market*

Is this for the hospital, RHC or Clinic?*

Select or enter value

Priority*

High = 2 week Medium = 3 weeks Low = 1 Month+ out

High

Medium

Low

Service Line*

Estimated budget for this request*

Provider name(s), provider or service line volumes

What is the situation? (New extended hours, new lo

Who is the audience?

What are the campaign objectives?

What's the strategy?

What grasssroots efforts are in place/in process?

Requested Channels*

Newspaper Ad

Radio Spot

TV Spot

Outdoor board

Social

Display

Native

Pre-Roll

Direct Mail

Magazine

CTA*

What are we asking consumers to do? i.e. go to anytime.com, call XXX-XXX-XXXX to schedule an appointment, sign up for seminar, etc

Who's on it?

Select

How do you plan to track?*

How do you plan to track the success of this campaign? volume numbers/ procedures/ calls/ attendees if it is for an event/ etc.

Additional Information*

Please include any additional information the agency would need to consider to incorporate your request.

File Upload

Drag and drop files here or

Send me a copy of my responses

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