Semi-Custom Live Theme-Change Santa Rosa CA, PBHS

We appreciate your business!

To get started on your website upgrade, please review the following questionnaire and fill in the blanks.
If you need any help as you fill out the questionnaire, please don't hesitate to reach out.

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
Text Message

About the Practice

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

Practice Name
Doctor Name(s)
Address(es)
Phone
Procedures Listed
Slogan
Mission Statement
No, they're all the same

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*

Procedure Changes*

Please list the changes you need in your procedures menu

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

What is your slogan/motto?

What is your mission statement?

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

Accepted file types: jpg, gif, png, eps, pdf, ai, Max. file size: 4 GB.

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

Alternate Logo Version

Accepted file types: jpg, gif, png, eps, pdf, ai, Max. file size: 4 GB.

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

Please list any social media accounts that link to your practice:

(Facebook, Twitter, YouTube, Instagram, etc.)

Design Selection

Please go to www.dentalfreeway.com to 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.

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.

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?

Additional Notes/Comments/Questions

Do you have any other comments or questions?

What's Next?

Upon receipt of this questionnaire, we will proceed making the provided changes to the live website. Please expect a 1-2 week turnaround time. Once the changes are completed we will send you instructions for editing the website. You will be able to change the menu options, edit text, add photos and links, etc. Please let us know if you have any questions or would like a demonstration; our support team will be happy to schedule some time to show you how it works.

Initials

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