Semi-Custom Current Client Questionnaire (No SEO) Santa Rosa CA, PBHS

Thank you for choosing PBHS to develop your internet presence. To get started, please review the following questionnaire and fill in the blanks. The typical turnaround time from when I receive this questionnaire back is 1-2 days, however additional customization or content imports may delay that a bit. If you need any help as you fill out the questionnaire, please call 800-840-5383 and ask for your account manager.

Who is your PBHS Account Manager?

Communication Methods

Primary Contact Person*

First Last

Email to contact you*

Best number to reach you*

This could be your cell phone, and will not be used on the site

Preferred Contact Method*

Email
Phone
Either

About the Practice

Have any of the following changed from what is listed on your current website with us?*

What is your practice name?*

Doctor Names and Credentials*

Please list all doctors as you want them listed on the website.

Office Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone Number*

Do you have another address to add/change?

Yes
No

2nd office address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please list additional office locations in the comments field at the end of this form.

2nd Office Phone

2nd Office Fax

Do you have 3rd office?

Yes
No

3rd Office Address

Street Address Address Line 2 City State ZIP Code

If you have more than 3 offices, please use the comments section at the end of this questionnaire to list the additional office info.

3rd Office Phone

3rd Office Fax

Nearby cities

Please list 6 neighboring cities from where you draw patients, for competing site verification

Do you want to use the exact content from your current website, or start with our new content?*

New Content (recommended)
Content from current site

We will copy over to the new site all customized pages - bio, forms, etc. if you start with new content

Affordable Care Act

Do you accept Medicare or Medicaid?*

Yes
No

Contact Information

The following is contact information that will be reflected on the Non-Discrimination page of your website. In many instances it will be the same as your normal practice information, however, in some cases it will be more specific. Please provide data for each field; all fields are required by the ADA.

Covered Entity Info

The covered entity may be your practice or your corporation.

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

TTY number - if covered entity has one

Do you have 15 or more employees?*

Yes
No

Office Coordinator Info

The office coordinator is the person in your office who will be contacted by the client via the Non-Discrimination page. This could be the Office Manager, Practice Administrator, Owner of the Practice, etc.

Name*

Title*

Coordinator Email*

Project Materials

Do you have a new logo?*

Yes
No
It's in process

Attach logo file

Only the following file types are allowed: eps, ai, jpg, gif, png .eps or .ai is preferred for the best quality

Alternate Logo Version

Only the following file types are allowed: eps, ai, jpg, gif, png .eps or .ai is preferred for the best quality

Do you have Social Media Accounts?

Please list any accounts that link to your practice (Facebook, Twitter, YouTube, Instagram, etc.)

Website Design Preferences

The following questions are in regard to the way the website will look and function.

Design Selection

Please go to www.dentalfreeway.com and click on Site Samples, and then your specialty. Review the different designs, looking at layout of content and different features on the site.

Which template would you like to use?*

If you can't decide, then enter "PBHS choice" here and we'll choose a design for you. We need your logo and this questionnaire filled out with as much detail as possible in the sections below in order to choose a design.

What's your 2nd choice?*

In case your first choice is already in use by another client in your area, what is your second choice?

Color preference

Do you want logo colors, dark, light, bright, pastel, etc.

Does your practice have a slogan or motto you'd like on the homepage?

Does your practice have a mission statement?

Do you want the mission statement on your homepage?

Yes
No

Office Email*

This email address will receive the contact form submissions from your website. We recommend using a contact form instead of posting your email address, which can invite spam.

What are your office hours?

Is there anything special you'd like to emphasize on your site?

Content Section

These questions pertain to the menu options (navigation) and content of your site.

Content Import....

Since we'll be importing your content from your current site, please indicate if there are any changes that should be made. For example, do you want to remove a doctor? Do you want to add a new procedure? Did you see a topic of content on the sample site, that is not on your current site and you'd like to add it?

Please choose your specialty*

General Dentistry Topics

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

Preventative Dentistry Section

Restorative Dentistry

Cosmetic Dentistry Section

Sedation Dentistry Section

Dental anxiety and phobia
Nitrous oxide
Oral sedation
IV sedation

Meet Us Section

Meet the doctor
Meet the staff
Office tour
Smile gallery (must provide own cases)

Oral & Maxillofacial Surgery Topics

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

Procedures Section

Please note that Dental Implants, Bone Grafting and Wisdom Teeth have additional sub-pages that you'll need to review once the site is posted in its temporary location.

Surgical Instructions Section

Referring Doctor Section

Referral form
Study club
Links of interest

Periodontal Topics

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

Periodontal Services Section

Dental Implants Section

Endodontic Topics

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

Procedures Section

Referring Doctors Section

Prosthodontics Section

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

Restorative Dentistry Section

Cosmetic Treatments Section

General Dentistry Section

Pediatric Dentistry Topics

Patient Information Section

Pediatric Dentistry Section

Orthodontics Section

Removable appliances
Type of bites
Classification of teeth

Orthodontic Topics

We will automatically copy over your current Home, Meet Us and Contact Us sections, as pages such containing PDF or online forms. Please indicate which of the following additional topics you'd like us to include from our stock content.

Patient Information Section

About Orthodontics Section

Braces Section

Braces
Retainers
Appliances
In-ovation system braces

Clear Braces Section

Clear aligners
Clear ceramic aligners
Clear aligners for teens

Invisalign Section

Living with Braces Section

Section Break

Content Notes

Do you have any additional comments or questions pertaining to the content on your new site?

Additional Notes/Comments/Questions

Do you have any other comments or questions?

What's Next?

Once the site is ready, we will send you a link to review it. Please give us a call at this time so we can talk about the design customizations you'd like us to make for you.

We will also send instructions for editing the content. Please let us know if you have any questions or would like a demonstration; we will be happy to schedule some time to show you how it works.

I look forward to working with you and your practice!

Email

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