Website Application

Website & Media Application Form
This application will help us build a website that represents you and your practice. The more accurate your answers are, the more unique and compelling your website will be. We recommend pulling up your current website (if you have one) before you start filling out the application. Let's get started!
1. Contact Information

This will be used to contact and coordinate throughout the development and production process.
Practice Name:
Current Website URL (If Applicable):
Write desired URL if there's no practice website.
Practice Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Manager's Name:

First NameLast Name
Office Manager's Cell Number:
Format: (000) 000-0000.
Office Manager's Email:
Doctor's Name:

First NameLast Name
Associate Doctor's Name: (If Applicable)

First NameLast Name
2. Website Details

This ensures we have the correct basic information about your practice from the start of the design process.
Practice Business Number:
The number you wish to display on the website.Format: (000) 000-0000.
Practice Business Email:
Will be displayed on website.
Business Hours:
Do you have a logo?
Please select the services you'd like featured on your website. Be specific. If you don't see one of your services on here, please write it in.

Other
Do you have any 3rd party integrations (such as online payment processing, scheduling, new patient forms, etc.) in use in your current website?
If so, please list which services need to be carried to your new site:
Choose up to three words that would best describe your ideal website:
Please list any insurance providers that your practice accepts and any other financial policies/in-office payment plans we should be aware of:
Is there a rescheduling and/or cancellation policy on your website? If so, please explain.
What makes your practice stand out?
Do you offer free consultations? Do you have modern technology? Do you offer an in-house insurance or payment plan? Are you family-friendly? Are you involved in the community?
List a few reasons why you aren't happy with your current website.
If no website exists, explain your goal with the new site.
What are some specific changes you'd like to see on your new website?
Please copy and paste at least one link to a website you like and explain briefly explain what you like about it:
This gives us a much more accurate idea of what you're looking for in your website design.
3. Current Website Host

If you don't
Who hosts your current website?
If you're unsure, please write 'I don't know.' We will need this information before launching your new website.
Please provide their contact information:
Phone and/or email preferred.
Do you have email services from your current website host or internally using your domain (e.g. info@yourdomain.com)?
4. Media Production

The standard pricing for the photo + video shoot is $1,500. This includes ONE overview video of your practice (without audio) to display on the homepage of your website, headshots of the staff and photos of the office. Your office is responsible for travel costs. Once this form is filled out, we will be contacting your office manager to pencil down a photo + video shoot day.
Does the doctor(s) want a new headshot? (Included in Standard Package):
Do the staff members want new headshots? (Included in Standard Package):
The typical overview video focuses on details of your office, patient and staff interactions, and the use of special technology. Please explain any additional content you'd like included in your home page hero video.
5. Scheduling

Appointment requests are processed on a FIRST COME FIRST SERVE basis. Please review availability below and select a day and time that best suites your practice's schedule, keeping in mind the availability of the patient you intend to include in the production process. The typical shoot lasts 3 hours and we only schedule Tuesdays through Thursdays to account for travel days. You will receive a confirmation email in the near future regarding your appointment.
Select desired day.

MonthDayYear
We operate Tues-Thurs to account for potential travel time.
Time Slot
Standard Photo + Video takes 3-4 hours.
Important: Please read our terms of service

Kana Productions Terms of Service for Website and Media Production
I have read and agree to terms
Name

First NameLast Name
Signature
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Website & Media Application Form

1. Contact Information

2. Website Details

3. Current Website Host

4. Media Production

5. Scheduling