Paid media audit & growth opportunities.
An outside review of YTD 2026 Google Ads performance for the Los Altos practice, with prioritized opportunities to discuss together.
Plotted by impact and effort. Start lower-left.
Each surfaced in the YTD data. Each has a defensible explanation from inside the agency we don't have full context on. Each is a conversation worth having this month.
Investigate the paused channels
Five channels with lowest YTD lead cost were paused around Feb 1. Down-funnel quality unknown without agency context. A diagnostic conversation, not a directive.
Replace income proxy with intent signals
Today's targeting filters by wealth tier (Avid Investors, Affluent). Premium-qualified searchers not tagged that way are excluded. Same premium audience, better signals.
Right-size Performance Max
PMax claims 48% of conversions on 17% of spend. The traffic signature suggests heavy Display blend and likely overlap with branded queries.
Fix tracking and copy
One conversion goal has never fired. Ad copy has known policy-trigger language. Both are low-effort fixes that unlock cleaner data.
January peaked at 107 conversions. The four months since have averaged 4x the cost per conversion.
A behavioral shift around Feb 1 moved this account from a $66 cost-per-conversion into a $260-310 range. The data does not tell us why settings changed. Context from the agency will.
Brand $9, original PMax $32, After Hours $38, Cosmetic LP test $54, Near Me $133. Lead cost only — down-funnel quality unknown.
New PMax variant at $123-208 CPA, launched Search Emergency at $859 CPA, and more budget into Search General at $238 CPA.
6 shared negative-keyword lists, 3,300+ unique negatives across 11 campaigns, 10-line service segmentation. Foundation is sound.
Ten audit dimensions. Two healthy, three to watch, five with growth headroom.
Healthy means working — preserve. Watch means fixable issues. Opportunity means the next growth chapter is here.
Account structure
10-line service segmentation, clean naming, brand-isolation design.
Negative keywords
3,300+ negatives across 6 shared lists. Top-quartile work.
Conversion tracking
4 goals configured. Book Appointment has fired 0 times.
Budget pacing
$8.2K/mo against $17K allocated. Max-conv throttling.
Bid strategy
All Max Conversions. 10 months of data warrants tCPA upgrade.
Campaign activation
5 lowest-CPA campaigns paused. Down-funnel quality requires agency context.
Audience signals
Income proxy targeting. Intent + first-party signals would qualify better.
Channel mix
17% PMax with traffic-quality questions. Brand off skews PMax CPA.
Ad creative
Single RSA on 81% of ad groups. Policy-trigger superlatives caused PMax limits.
Keyword waste
38% of keyword spend ($6,716) on zero-conv keywords YTD.
Strategic levers.
Audience signals and channel mix. The two decisions that compound every tactical fix below them.
Targeting filters by wealth signal, not buying intent.
Premium positioning is the right strategy for this practice. The question is whether Google's wealth-proxy audiences are the right way to reach those premium buyers.
Premium-by-income-proxy. Wealth-tier filters miss qualified prospects.
Performance Max asset groups themed around Tech Workers, Affluent Audiences, Recent Movers, Banking & Finance Avid Investors, Beauty & Wellness. The Cosmetic-Professionals audience explicitly targets investors. Search has no audience layering at all.
Same premium audience. Found through intent, not income proxy.
The practice's positioning stays high-end. The mechanism to find that audience shifts from wealth-tier filters to active-intent and first-party signals. Slightly broader reach, same premium quality of prospect.
Anchor on active cosmetic intent, supported by first-party data.
Intent signals capture wealthy buyers who aren't tagged "Avid Investor" but actively search "veneer dentist Los Altos" or "smile design." Lookalikes from the practice's own past cosmetic patients seed similar premium-buyer audiences. Premium positioning preserved. Financing-led copy stays one possible angle to test — not the lead angle.
Performance Max claims a $62 CPA. The traffic signature says be skeptical.
Click-through rate is a clean tell for what network actually serves the ad. Pure Search lives in 3-8%. Pure Display lives in 0.3-0.8%. PMax sits wherever its mix sits.
Behaved like Search
Behaves like Display
Pure intent traffic
Search-first. PMax as a secondary lever, once Brand context is restored.
Resequence rather than restructure. Restore Brand search first so PMax can be evaluated against branded traffic it currently absorbs. Then resize PMax to a 10-15% test budget.
17% in PMax, no Brand running
Search-first, Brand on, PMax capped
Order: 1) Reactivate Brand search to defend against competitor conquest. 2) Resolve PMax policy limitations and reactivate the original PMax with brand exclusions; pause the current PMax General. 3) Resize budgets to the 72/13/15 split and switch eligible Search campaigns to Target CPA once Book Appointment tracking is fixed.
Tactical fixes.
Paused-campaign review, ad creative, tracking, and a 30-day plan to sequence the work so each step unlocks the next.
Every campaign ranked by lead cost. Pause history is the conversation, not the verdict.
Cost per conversion is the lead cost — not the cost per booked-and-treated patient. Without offline conversion data, a $9 lead and a $700 lead can look identical down-funnel. The agency knows which paused channels brought consult-attended cosmetic patients. We don't yet.
Low lead cost doesn't equal best down-funnel performer.
Brand at $9 likely catches existing patients searching the practice name — cheap conversions, but not net-new acquisition. PMax #1's $32 may have absorbed similar branded queries while Brand was off. The conversation to have with WNDR: which of these paused channels brought consult-attended cosmetic patients? That's the data we need before reactivating.
Today's copy is generic premium. Test against credible-premium.
The current ads lean on unverifiable superlatives (Renowned, Top, Award-Winning) that contributed to PMax policy limits. A credible-premium variant replaces those with verifiable trust signals while keeping the high-end positioning intact.
Four conversion goals configured. One has fired zero times.
Three of four conversion actions are reporting. Book Appointment has fired zero times in 133 days. Smart Bidding optimizes against what it can see, so a broken goal misleads the algorithm.
The booking widget is missing its conversion tag
The NewPatientSpecial booking completion page either does not have the Google Ads conversion tag installed, or its trigger condition is misconfigured. Easy to verify with one test booking.
Secondary item: the Contact goal fires 220 times YTD. Verify what event counts as a Contact — if it's page views rather than completed contact-form submissions, it inflates conversion volume and depresses reported CPA.
Three phases. Each unlocks the next.
Week one is diagnostic and repair, no new spend required. Restructure in weeks two-three. Audience and creative tests in weeks three-four.
Investigate and fix tracking
- Get WNDR's pause rationale for each of the 5 January-paused channels.
- Pull consult and treatment data per source to verify down-funnel quality.
- Test the Book Appointment trigger end-to-end. Verify the conversion tag fires.
- Pause zero-conv keywords with $200+ YTD spend each.
- Verify Contact goal definition. What event actually counts?
Restore defensive Brand, fix PMax
- Reactivate Brand campaign at 95%+ IS for competitor defense.
- Resolve PMax policy limitations. Remove unverifiable superlatives.
- Reactivate the original PMax with brand exclusions and Customer Match signals.
- Pause current PMax General once the original is back live.
- Switch Search General and Sedation to Target CPA after 14 days.
Better signals, credible-premium creative
- Upload Customer Match lists from the practice CRM. Existing-patient exclusion + cosmetic-patient lookalike.
- Add Custom Intent audience built from cosmetic research queries.
- Add credible-premium RSA as second variant in cosmetic ad groups.
- Replace policy-risk superlatives with verifiable claims everywhere.
- Weekly performance check-in against down-funnel benchmarks, not just leads.
Re-anchor the account on patient outcomes, not lead volume. The metric that matters for this practice is consult-attended cosmetic patients per dollar spent. Once Book Appointment tracking is fixed and Customer Match offline-conversion data flows back, every lever above can be evaluated on revenue, not lead count.