New Website Intake Form

Website Intake Form

We are so excited to be creating your website! Please anticipate 15 minutes to complete this form with as much detail as possible, and we recommend completing it on a desktop computer. This will ensure our designers have all the information necessary to build your site as quickly, accurately and efficiently as possible to get your site live and more clients through the door. All form field are required, if you do not have an answer for a question, simply input "NA". Thank you.
Name Of Business (no symbols please).*
Your Name*

First NameLast Name
Your Personal Email (Preferred email for contact from us)*
example@example.com
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email (To be placed on website)*
example@example.com
Business Days & Hours*
Instagram Handle
@instagramname
Business Facebook Page

Your New Website
Information on Existing Website

In this section we will collect information about your existing website. If you do not have one, please input "NA" and skip to the next section.
Link To Your Existing Website*
In what ways is this site falling short?*
Do You Have An Online Booking System?

YesNo
Please Provide Link To Booking System*

Your New Website: Content

Please create a link in Google Drive with any specific content, photos, logos, promo information (for pop ups) etc. that you would like on the site. Make sure the link share setting is set to "Anyone with Link". We do not share your information. We have included 2 instructional videos below on how to create your Google Drive folder and how to organize and share it with us at the bottom of this page.
30-Second Video: How to Create a Google Drive Folder

90-Second Video: Organize + Share Google Drive Folder
What device(s) do you have? (Opus Plasma, Alma TED, Harmony XL Pro, ClearLift, DYE VL, etc,)*
How do you refer to your customers?*

"Patient""Client"

Please list THREE blog topics you would like us to write about for your new website.*

Rows	Topic Name
Topic 1 (ex: Benefits of laser skin services)
Topic 2
Topic 3

Please list ALL services you offer (each service will have its own page) - if a service has an add-on option, put the add-on option in parenthesis. For example: Microneedling (Add-On Option: PRP) - these will go on the same page. Note: for services that are unique or with a vague title (e.g. "Skin Care"), please provide more details about what your business does so that we can create the most accurate information page as possible. For IV therapy services, please list all IV kits you offer.*
We will include all services on your home page, however if you would like any specific services or devices featured in their own section on the home page, please list them here: (limit 4)*
Will your website have a shop?*

NoYes - we are affiliated with a company such as ZO, AlumierMD, etc. and have a link for themYes - we will ship products from our physical location
Please list all NON-SERVICE pages you will need for your site. If you would like a shop page, or are affiliated with specific products, please list those in parenthesis. For example: "Shop (AlumierMD, ZO Skin)" and provide your specific links if applicable. Non-services pages we recommend for every site: About, Contact Us, Privacy Policy*
Would you like a pop-up for a promotion you're running? (If yes, please make sure to include this information in your Google Drive folder in the form of a Google Doc entitled "Promo Pop Up" with what the promotion is (service / price or discount))*

YesNo
Please place your Google Drive folder link here:*
ATTENTION

Please make sure to schedule a homepage review through the link in your onboarding email.

PatientQ provides web hosting, maintenance, and reporting from the date the website is launched per the purchased package. After the package time, you will receive an email 30 days prior to your hosting and reporting ending, to continue these services with PatientQ for a monthly fee.
*

I have read and understand that PatientQ provides website hosting, maintenance, and reporting per the purchased package. After this set amount of time, I understand that I will have the ability to continue these services with PatientQ for a monthly fee.
Signature*
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Website Intake Form

Your New Website

Information on Existing Website

Your New Website: Domain & Branding

Your New Website: Content

ATTENTION