Why Are My Google Ads Showing in the Wrong Cities?

A clinic owner called us in July, frustrated and a little embarrassed. He had been running Google Ads himself for three months, spending about 2,000 dollars a month, and the phone was barely ringing. When we opened the account, the problem was sitting in plain sight. His practice is in a mid sized Ohio town. His ad clicks were coming from Dallas, Phoenix, two towns in Florida, and a handful of places he had never heard of. He was paying real money, every day, to show his ads to people who could not possibly become patients.

He had not done anything wrong, exactly. He had done the thing Google nudges almost everyone to do: he left the default location setting alone. That one default is the single most common reason a local medical practice sees its ads show up, and its budget disappear, in the wrong cities.

The one setting almost nobody checks

When you build a campaign, Google asks which locations you want to target. You type in your city or draw a radius, and it feels done. But hidden one click below that, under a "Location options" menu, is a choice that matters more than the map itself. Per Google's own location targeting documentation, you get two real options:

• Presence or interest. This is the default, and Google labels it "Recommended." It shows your ads to people who are in your area, and to people anywhere who have shown interest in your area. Searched your city name, read about it, looked it up for a trip. All of them can see your ad.
• Presence. This shows your ads only to people who are actually in, or regularly in, the places you targeted.

Read those again and the trap is obvious. "Interest" is a wide net. Someone in another state planning a visit, a former resident who still follows local news, a person who simply typed your town into a search for any reason, these are all "interested" in your area as far as Google is concerned. For a travel brand or a hotel, that reach is useful. For a dentist who needs a patient to physically sit in the chair, it is pure waste. Google recommends the loose setting because it spends your budget faster, not because it books you more patients.

How to tell if it is happening to you

You do not have to guess. Google keeps a report that shows where the people who actually saw and clicked your ads were physically located, which is different from the locations you told it to target. In the campaign, open the location settings and look for the user locations view, often labeled "Where users were." That is the truth. The list of places you targeted is the intention. The user location report is reality.

Open it and scroll. If you see clicks, impressions, and spend stacking up in cities well outside your service area, you found your leak. Most practice owners running their own ads have never opened this report, which is exactly why the money can bleed for months before anyone notices. If you want the bigger picture on where your spend vanishes, we broke it down in why your Google Ads budget runs out so fast.

Why this hits a medical practice twice as hard

Every business wastes a little on bad geography. A medical practice feels it more for two reasons.

First, patients are deeply local. In the 2026 U.S. News survey on how people choose care, 62 percent called a provider's location "very important" for routine visits. People pick the office they can get to, near home or near work. So an ad shown to someone far away is not just low value, it is zero value. They were never going to book you.

Second, healthcare clicks are expensive. A click for a competitive term like "dermatologist near me" or "urgent care" can run several dollars, sometimes well into double digits for surgical and cosmetic terms. When each click costs that much, a third of your budget leaking to the wrong map is not loose change. It is the difference between a campaign that books patients and one that makes you want to quit on paid ads entirely. And it poisons your numbers too: those dead clicks drag down your conversion rate, so a campaign that is actually fine on the local traffic looks broken on the dashboard. We see owners pause good campaigns over this exact illusion, which is part of why some conclude their Google Ads patients are lower quality than their SEO patients when the real culprit is targeting.

The fix, in order

1. Switch the setting to Presence

This is the big one and it takes thirty seconds. In each campaign, open Settings, expand Locations, click "Location options," and change the target choice from "Presence or interest" to "Presence." Now only people in your area see your ads. For the vast majority of local practice accounts, this single change is the right call, and it is the first thing we flip when we take over a messy account.

2. Exclude the places you never want

If a few far off cities keep slipping in, add them as excluded locations so Google can never spend there. You can exclude a whole state, a metro, or a single town. Think of it as a fence around your budget.

3. Match the radius to real drive times

A tight radius around your office beats a sloppy one every time. Set it to how far your patients actually come from, not how far you wish they would. A family practice might serve five to ten miles. A specialist patients travel for can go wider. We walk through the full logic in how far you should target your Google Ads.

4. Watch the location report for a few weeks

Targeting is not a set it and leave it job. Check the user locations report every week or two at first, and trim any area that keeps spending without booking. Patterns show up fast once you are looking.

5. Track what turns into real patients, not just clicks

Clean geography only pays off if you know which clicks become appointments. Call tracking and simple conversion tracking tell you which areas, keywords, and ads actually fill the schedule, so you can pour budget into what works. Our guide to tracking where your patients come from covers the setup.

Where EtherealMinds fits

None of this is complicated, but all of it is easy to miss when you are also running a practice. A busy owner does not have time to audit a location report on a Tuesday night, and the defaults are built to look fine while they spend. That is the whole reason a loose setting can run for months.

When we manage patient acquisition and Google Ads for a practice, tight location targeting is table stakes, not an upgrade. We set every campaign to Presence, fence off the areas you do not serve, build the radius around your real patient drive times, and then actually read the location report so your budget stays on the people who can walk through your door. For the "near me" searches where paid ads and free listings sit side by side, we pair that with local SEO so you show up in the map pack too, not only in the ad slot. And because a tighter campaign means more of the right calls, our AI receptionist answers every one and books the appointment, so the money you stopped wasting on the wrong cities turns into patients instead.

So, why are your Google Ads showing in the wrong cities? Because Google's default wants it that way, and nobody told it otherwise. Change one setting, fence your map, watch the report, and you can win back a chunk of budget you did not know you were losing, without spending an extra dollar. The patients you want are the ones down the street. Stop paying to reach the ones who will never come.