Silent Partner TV Setup Questionnaire - GP Santa Rosa CA, PBHS

Doctor Name(s)*

Please include ALL doctors on this account.

Website URL

example: www.mywebsite.com or www.pbhs.com

Contact Phone Number*

Contact E-mail Address*

If PBHS Support has any questions, we would like to use this e-mail to communicate.

If you have a TV screen in your waiting room currently, what are you showing on it?

Do you want us to include your Launch Video in your playlist?*

(Launch Video is a paid service provided by PBHS. If you DO NOT currently pay for this service through PBHS, then select the 'I don't have Launch Video' option.)

Yes
No
I don't have Launch Video
I don't have Launch Video, but would like to be contacted to learn more about this product

Do you want us to include your Launch Survey testimonials?*

(Launch Survey is a paid service provided by PBHS. If you DO NOT currently pay for this service through PBHS, then select the 'I don't have Launch Survey' option.)

Yes
No
I don't have Launch Survey
I don't have Launch Survey, but would like to be contacted to learn more about this product

Do you want us to include any videos from YouTube?*

Yes
No

Please copy and paste the URLs to the YouTube videos you want to include

Click here for instructions on finding the URL to the video(s) you would like.

Do you want us to link your Facebook page?*

Yes
No
I don't have a Facebook page

Please provide your business Facebook page URL:

Facebook Page Login Email:

Note: If these credentials are not provided or are inaccurate, PBHS will not be able to set up Facebook integration.

Facebook Page Login Password:

Note: If these credentials are not provided or are inaccurate, PBHS will not be able to set up Facebook integration.

The Silent Partner system comes with educational procedural video preloaded. Please select any additional categories you would like included:*

**You can select/deselect the options provided below.

Dental Implant Overview
Dental Implant Testimonials

The Silent Partner system comes with a news ticker (chyron) that plays at the bottom of the screen and can be customized with different news feeds. Please select all the categories you would like displayed:*

**You can select/deselect the options provided below.

The Silent Partner system also comes with optional Entertainment YouTube videos. These videos are curated and automatically updated periodically. Please select any of the following categories you would like on your device:*

NOTE: These videos are streamed directly to the ADA TV device and require a robust internet connection to function reliably.

**You can select/deselect the options provided below. Click here to view examples of this content.

During the COVID-19 crisis, we realize that your office may be closing down during this time. We ask that you confirm if your office will be open or closed before we can ship your completed ADA TV.

Note we can ship your ADA TV to an alternate address (home or other address), noting that billing will start 2 days after shipment.

Please let us know what option you prefer below:*

Ship the ADA TV to my office, it will remain open
Ship the ADA TV to an alternate/home address, I am aware billing will start 2 days from shipment date.
Hold the shipment of my ADA TV until I confirm my office is reopened (billing will not start until shipment is granted by you or your office staff)

What address(es) would you like us to ship your ADA TV to? (If you have ordered multiple devices, you may include multiple addresses.) NO PO BOXES*

Thank you for completing this form. Please click the "Submit" button below.

Upon shipping we will email you a tracking number.

Initials

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