HyperLocal Listing Optimization Questionnaire

This questionnaire must be completed all at once. If you are not able to complete the questionnaire due to time constraints, scroll to the bottom and submit what you have finished so far. You can revisit the other questions later or during your consultation. Please include your Name, email and website on all submissions.

We will also need access to your Google Business Listing. Please follow the directions in your Welcome email to add our account as a Manager to the listing.

Client Name*

Website*

If your site is still in development AND you do not have a website address yet, please enter http://www.nodomain.com in this field.

Email*

A copy of the questionnaire will be sent to this email address once the form is submitted

Primary Contact(s)

Please include First and Last Name and Phone Number

What Practice Management Software do you currently use?

What is your legal practice name?

Do You Do Business under a different name from your legal practice name? (DBA)

If Yes, What is that name?

Practice Address(es)*

Include Suite Number, if applicable

Previous Information for Business Location(s)

If the location was recently purchased, please supply the information for the previous business, including practice name and any doctors that were associated with the previous practice. If you do not know the previous owners information, enter "I don't know".

Practice Phone Number(s)*

Each location must have a unique, local phone number. Please contact us if you are unable to provide a unique number for each location.

Languages

Payment Accepted

Year Established

Do You Want Your Office Hours Listed on Directories?

Recommended

Yes
No

What are Your Office Hours?

Practice Photos

There are several directories that allow photos. I post the office tour photos when they’re available. May I post your personal photo?

Yes
No

Previous Associates

Have any doctors left the practice in the last few years. We can work to close old listings referring to them at your location.

Yes
No

Please List Previous Associates

Please include their first and last name.

Additional Information

Additional Comments/Questions

Website

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

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PBHS Hyper-Local Optimization Questionnaire

Additional Information