Society & Non-Dental Questionnaire 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

About the Business

What is your business name?*

Names and Credentials*

Please list all people as you want them listed on the website under Meet or About Us

Office Address*

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

Office Phone Number*

Office Fax Number

Do you have 2nd office?

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

Project Materials

Do you have a 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 any of the specialties - it doesn't matter which one because the designs are the same among all specialties and we're only looking at layout here, not content.

Review the different designs, looking at layout of content and different features on the site - where the navigation is, how big the banner images are, placement of buttons, etc. We still start with one of these for layout, and then customize it with your content and pictures.

You can use the comment section to let us know if you have a website already with content you'd like to use, or request to use applicable stock content that we have.

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.

Do you have a slogan or motto you'd like on the homepage?

Do you 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.

Do you already have a website?*

Please list anything you'd like us to pull from your current website into your new one.

Content Notes

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

Domain Questions

Please fill out all questions below. We cannot post your website live without this information.

Do you have a website address?*

Yes
No

Website Address:*

Where is the domain registered?*

Username for your account?*

Password for your account?*

I would like this website address:

We will register the address above on your behalf if it is available. One domain is included with your order. Additional ones can be registered for a fee. Each domain is $70/year for the renewal.

Do you currently have any email addresses @ your domain name?*

Yes
No

Do you want PBHS to host your email accounts?*

Yes
No

Selection: No email with PBHS

You have selected NO on whether you want PBHS to host your email. When you're ready to go live, we will give our IP Address to you or your IT person to update on your domain settings. Please list the contact info for the person in charge of your domain name settings for this update.

Selection: Email with PBHS*

You have selected YES on whether you want PBHS to host your email. Please list ALL email accounts currently in use so we can set them up on our server.

How do you check your email?*

Outlook
Webmail

** Please be aware that if you are using Webmail, you will lose all stored email and address books upon hosting switch to PBHS. You will need to save this data first either by downloading to outlook, forwarding to a different email address (yahoo or gmail for example) or printing them. For further instructions on backing up this data, please contact your current email host. After your new site goes live, you can contact [email protected] or 1-888-840-0739 for assistance with email setup on our server.

Do you want PBHS to manage your domain name?*

Yes
No

We charge $70 per year to renew each domain name. If you select No (or leave it blank), you understand that PBHS will not be responsible for expired domains, loss of domain name or website and email data. Furthermore, you will be solely responsible for receipt of and action upon notice for renewals or other required actions from PBHS and/or the domain registrar. You understand that if you fail to receive and/or act upon such notices, that the website and email accounts my no longer be accessible from the Internet.

Additional Notes/Comments/Questions

Do you have any comments or questions?

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.

Our goal is to execute your web marketing plan in the timeliest manner possible. For this reason, if after 30 days, we do not have this questionnaire back, we will move the project along on your behalf. This includes choosing a design, posting the site in a temporary location, starting your hosting fees and charging the remaining balance. The designs can be changed at any time through your admin screen and you will be emailed instructions on how to do so along with editing the website. If you have any questions or are unable to send the necessary materials within one month, please give us a call right away. I look forward to working with you and your practice!

Name

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