Secure Video Questionnaire Santa Rosa CA, PBHS

Your Name*

First Last

Website*

Account Settings

The following questions are for your general account setup. This information will be visible to your patients.

Doctor or Practice Name*

This will be what patients see on email headings and the login screen.

What is your time zone?

Phone Number*

Most likely your office number, this is the number patients will see on their communication from you.

How do you want to be notified about appointments

Email
Text Message
Both

Scheduling Email Address*

This is where all communication, notifications, reminders, etc. will go for appointments.

Mobile Phone

Which office(s) will be seeing patients?

We're including a link to TruForm if you have it, and need to know which form to link.

Payments & Services

You have the option of collecting online payments for the teledentistry appointments, either before or after the visit. If you'd like to set this up, we will need to create a pick-list of services and associated times and costs.

Do you want to collect payments online?

Yes - my info is below
No
Yes - I'll set it up later

When you decide on a payment processor and set up your account, please email us at [email protected].

Select your payment processor

You will need to create your own payment account via Stripe, PayPal or Authorize.net. We will need some details from your account to complete the setup of your payment form.

You will need to grant PBHS administrator access to your stripe account for us to connect the payment form. The email address to grant us access is [email protected].

Authorize.net LinkID*

Please paste your LinkId from your Authorize.NET Simple Checkout Button. (Example: 521c2344-153e-177e-1753-2e41fa0a654b)

PayPal Email Code*

Please paste your PayPal code

Service Offerings

Consultation
Appointment Follow Up
Other

Consent Forms

We will have a stock consent form for patients to agree to televisits. Optionally, you can add your own forms for an additional setup fee.

Do you want to use our stock consent for teledentistry form?

Yes
No

Do you want to use a custom form? (additional fees apply)

Yes
No

Please upload .PDF, .docx or .doc files only

Drop files here or

Accepted file types: pdf, docx, doc, Max. file size: 1 MB, Max. files: 5.

Preference

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

Secure Video

Secure Video Setup

Account Settings

Payments & Services

Consent Forms