Launch Chat Questionnaire

Client Name*
Website Address*

e.g. www.domain.com
What Practice Management Software do you currently use?
What Hours Would You Like Phone Connect to Be Active Each Day?*
These are the hours the Chat Agent will attempt to connect users with the office phone. Most practices use their normal office hours, unless they have someone available to answer phones outside of that time. Please include times for each day, including any days you are closed.
During Office Hours, What Phone Number Would You Like to Use for Live Connect Leads?*

It is best to have a dedicated phone line, to increase successful conversions. We also recommend avoiding phone lines with Auto-answering or a phone tree that must be navigated before speaking to office staff.
What PBHS Secure Mail Email Address Would You Like to Use for Leads When the Office is Closed?*

We recommend using your PBHS Secure Mail email address, if you currently have an account. If you do not currently have an account, please list the email address you would like, and we will create one for you.
Initials
This field is for validation purposes and should be left unchanged.