Waiting Room TV Setup Questionnaire - Waiting Room TV Santa Rosa CA, PBHS

Practice Name:*

Website URL

example: www.mywebsite.com or www.revenuewell.com

Contact Phone Number*

Contact E-mail Address*

If RevenueWell Onboarding has any questions, we would like to use this e-mail to communicate.

Please select your practice specialty:*

Do you want us to include your Launch Survey testimonials?*

(Launch Survey is a paid service provided by RevenueWell. If you DO NOT currently pay for this service through RevenueWell, then select any other answer aside from the 'Yes' option below.)

Yes
No
I don't have Launch Survey
I don't have Launch Survey, but would like to be contacted to learn more about this product

Do you want us to include any videos from YouTube?*

Yes
No

Please copy and paste the URLs to the YouTube videos you want to include

Do you want us to link your Facebook page?*

Yes
No
I don't have a Facebook page

Please provide your business Facebook page URL:

The Waiting Room TV app also comes with optional Informational Marketing slides and videos. This content is curated and automatically updated periodically. Which of the following categories would you like included?*

**You can select/deselect the options provided below.

Botox
Clear Correct
Dental Implants (General Implant Overview, Nobel Biocare, Biohorizons and Yomi)
Health (HealthDay | http://www.healthday.com)
Invisalign
Straumann

The Waiting Room TV app also comes with optional Entertainment YouTube videos. Please select any of the following categories you would like on your device:*

**You can select/deselect the options provided below.

Consult Mode Information

Along with using your Waiting Room TV device(s) within your practices waiting room and/or additional TV's, you can now utilize shorter procedural playlists from a tablet or computer during the patient's chair side consultation using Consult Mode. Click here for further information on using Consult Mode in your practice.

Please select the Consult Mode Playlist(s) you would like:*

With the addition of Consult Mode, RevenueWell has predesigned the playlists listed below. This includes a combination of silent dental animations and images, which will help increase of case acceptance and patient education during the consultation. Additionally, you can build your own Consult Mode playlists at anytime. **Shared Playlists can be added or removed at anytime. **Shared playlists cannot be modified. Shared Playlists will be auto-updated by RevenueWell periodically with improved silent animations, slides and video's.

Consult Mode User Setup*

Although you can access Consult Mode using your MySecurePractice secure login, we require a secondary login for direct access to Consult Mode. This dedicated user account will be restricted exclusively to the Consult Mode section, ensuring that any potential PHI throughout your MySecurePractice account can't be accessed by the patient. Please provide this unique secondary email below.

How many TV/devices would you like Waiting Room TV setup on?*

Each TV/device within your location will need a unique login to play the Waiting Room TV playlist (this is for physical TV setup, not Consult Mode User Setup described in the above question). This can be setup by your onboarding team at no additional cost. Note, if you need to setup a NEW location - this would need a new proposal (@$79/mo).

For orders that include multiple offices:

If your office's provide similar procedures and share a common email, please select the checkbox below to apply the above settings for each location. If your locations differ in procedure's offered or email's used, please fill out this questionnaire individually for each location. The locations purchased can be confirmed on your order confirmation.

Apply settings for all locations

Agreement*

By checking this box you agree this is the content you want added to the Waiting Room TV, changes may be billable.

Thank you for completing this form. Please click the "Submit" button below.

Address

This field is for validation purposes and should be left unchanged.