Semi-Custom Redesign Questionnaire (Theme-Change) 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 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
Text Message

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*

Office Fax 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

What are your office hours?

Nearby cities

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

Office Systems & Workflows

RevenueWell + PBHS have many potential software integrated solutions to streamline office workflow from start to finish, beginning with a VOIP phone system, then online appointment scheduling, online registration forms and ending with patient reviews.

Practice Management Software

Appointment Reminder Software

Review Platforms

Other Review Software

Pre-Registration Forms

TruForm
RevenueWell Forms
Other
None

Other Registration Form

Would you like more information on any of these topics?

Yes
No

Please send me more information on:

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

Please list any social media accounts not already on your current site

(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.

Keep in mind that the colors and banner images can be changed on all sites to different scenic ones, people, or even your office. So choose based on overall layout and placement of elements, not colors and banner pictures.

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, bright, pastel, dark, 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.

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

Content Section

We will import your existing content into this new site. Please take a look at your existing website to answer the questions below.

Are there any new procedures you offer?

Are there any pages you'd like removed?

Did you see any new content on our examples you'd like to include?

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

Additional Notes/Comments/Questions

Do you have any comments or questions?

What's your target activation date?

Once you're ready to go live, you can plan for approximately 2-7 business days to allow for final checks and/or domain transfers to get the site live. We will do our best to help you meet this timeline.

Directory Listings

Part of the process is submitting the site to directories. There are a few additional items that several of the major directories have space for. Please complete the items that apply.

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?

Languages Spoken In Office:

Year Practice Established:

Practice Photos

Yes
No

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

Practice Address & Associates

Yes
No

Have you changed your address, phone number, website address or practice name or associates in the last couple of years?

Previous Practice Information

Please include old practice names, associate names, addresses and phone numbers.

What's Next?

Upon receipt of this questionnaire, we will post your new website on a temporary location and 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.

The website can be posted at any time, so please let us know when you're ready. Allow a few days time for final site review and domain transfers to post the site.

I look forward to working with you and your practice!

Initials

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

Semi-Custom Redesign Questionnaire (Theme-Change)