22
Kept exams
New patient growth case study · Q1 2026
From invisible in local search to 22 kept exams from Google.
How a leading two-location orthodontic practice in California built a measurable patient-acquisition system that brought the cost of a new case start down to $1,614 — about half the market rate (varies by region; conditions apply).
$84.5K
Verified production revenue
$1,614
Cost per case start*
$4.76
Return per $1 spent
*A case start is a patient who begins treatment (the conversion). Cost per case start varies by region, competition & treatment mix — conditions apply.
Executive summary
A system, not a campaign.
Practice photo
Most practices don't struggle with a lack of leads. They struggle to know which marketing actually brings patients through the door. A leading orthodontic practice in California solved exactly that in Q1 — by tracking every dollar to a booked appointment.
The goal was never to "run ads" or "publish blogs." It was to build a trackable system where every marketing dollar could be traced to a kept patient appointment, and every month's budget decision was driven by that data. Three channels — Google Ads, SEO and Local Services Ads — working behind one tracking layer that connected every lead to its source, every call to a campaign, and every appointment to a dollar amount.
The starting point
Before February. After April.
Before — Feb 2026
- Not on Page 1 for any local search
- No call tracking or booking attribution
- Slow booking experience, leads lost mid-form
- No Local Services Ads presence
- Broad keywords wasting ad budget
- Technical errors blocking Google
- No way to calculate cost per patient
→
After — Apr 2026
- Page 1 for all priority local searches
- Full call tracking + booking attribution
- Faster booking, conversion tracking live
- LSA live across both locations
- 63 negative keywords filtering waste
- Technical issues fixed, speed improved
- CAC tracked at $1,614 per case start
The 90-day timeline
Three phases, one direction.
The sequence is fixed because it has to be: foundations before content, content before optimisation. Each phase depends on the one before it being in place.
Phase 1
Foundations
February 2026
Tracking before spend
Call and booking tracking installed first — every call and form linked to its source before a dollar of ad budget ran.
Two separate campaigns
The two locations built as separate campaigns, each with its own budget, data and patient tracking.
63 junk terms blocked
Competitor names, job seekers, suppliers and out-of-area searches filtered on day one.
Result: lowest CPL of the quarter
February's cost per lead was $12.36 — an unusual result for a launch month, because the junk was filtered before launch.
Phase 2
Optimisation
March 2026
Budget followed patients
February's data showed which terms and locations produced booked appointments. March's budget was redirected to them.
Differentiators in the ads
Two locations, free consultations and local Invisalign expertise surfaced directly in search results.
Quality score climbed
Cleaner traffic and better click rates meant the practice paid less per click for the same positions.
Result: best month of the quarter
257 leads at $14.32 each — the highest patient volume of the quarter, with cost per patient dropping to $1,326.
Phase 3
Quality & growth
April 2026
Raised the conversion bar
Call threshold lifted from 5 to 60 seconds. A 60-second call is a real conversation, not a misdial — so the system learned to find genuine patients.
Local Services Ads launched
LSA went live across both locations — pay only when a real patient makes contact, with the Google Guarantee badge building trust.
Bidding unlocked more reach
In a market constrained by search volume, bid adjustments surfaced additional qualified searches.
Result: most patients of the quarter
Fewer reported leads, but 9 kept exams — the highest single-month count. Fewer numbers on the report, more patients in the chair.
Month by month
The full Q1 numbers.
| Month | Kept exams | Case starts | Spend | CAC | Leads | Status |
|---|---|---|---|---|---|---|
| February | 6 | 3 | $4,815 | $803 | 159 | Launch |
| March | 7 | 5 | $6,631 | $947 | 257 | Best month |
| April | 9 | 3 | $6,304 | $700 | 159 | LSA launched |
| Q1 Total | 22 | 11 | $17,750 | $1,614 | 575 | $84,590 |
CAC = cost per case start (a patient who begins treatment). Q1 CAC reflects total investment divided by 11 case starts; cost per case start varies by region — conditions apply. April's reported cost per lead rose as the quality bar was raised — yet it produced the most kept exams of the quarter.
Organic search · the compounding asset
Free patient traffic, at $0 ad cost.
Alongside the paid channels, SEO built an asset that keeps producing patients long after the engagement — at no additional cost per click.
1,100
Free website visits
236,600
Times shown in Google
Page 1
All priority searches
+27%
Impressions growth, Feb → Apr
Market benchmark
$1,614 per case start, against a $3,500 market.
Compared with published performance from established orthodontic and dental marketing agencies in similar markets. Not a criticism of other approaches — a data point on what tracking-driven execution achieves.
Established agency
Market benchmark
Cost per case start$3,500
Monthly agency fee> $5,000 / mo
Campaign approachBlended / regional
Call quality thresholdStandard 5-sec
SEO + Ads integrationSeparate engagements
Tracking depthReporting only
This engagement
Tracking-driven
Cost per case start$1,614
Monthly agency fee< $3,000 / mo
Campaign approachSeparate by location
Call quality threshold60-second verified
SEO + Ads integrationUnified engagement
Tracking depthPatient-level, GA4 + calls
A $3,500 vs $1,614 cost per case start is $1,886 less for every case — a substantial saving across the quarter, with no reduction in patient quality or production revenue. (Figures vary by region — conditions apply.)
Why it worked
Four takeaways for practice owners.
01
Track before you spend
Call attribution and booking tracking were built before the first ad ran. Every dollar was accountable from day one — practices that skip this can never truly measure what's working.
02
Separate your locations
The two locations are different markets. Separate campaigns revealed which location performed and let budget shift accordingly each month.
03
Organic pays for itself
1,100 visits and 236,600 impressions at $0 ad cost. Every Page 1 ranking is a permanent acquisition asset that lowers the average cost per new patient indefinitely.
04
Count patients, not leads
April had fewer reported leads but the most kept exams. The metric that matters is patients in chairs — not how many calls show up on a report.
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