Website Intake Form

Website Intake Form

This form will help you provide the key information we need to build your website. Please note that we cannot start building your site until this form is completed in full; please feel free to contact us if you have questions on any part of the form.
Office Details

We’re excited to bring your new website to life! To ensure a smooth and efficient process, it’s important for us to have one main point of contact or decision-maker in your practice. Of course we encourage you to collaborate with your team, but once a decision is made, we'd like to receive that information from one consistent person. This helps us deliver the best possible results in a timely manner. Thanks in advance for helping us keep things moving seamlessly!
Decision Maker/Contact Name:
Decision Maker/Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Decision Maker/Contact Email:
example@example.com
Full Practice Name
Please do not use abbreviations or acronyms – we need the full name of your practice to be displayed on the site for clients who may not have heard your name before.
Business Owner's Name
Practice Phone
This should be the direct practice phone number and not a tracking number of any kind.Format: (000) 000-0000.
Practice Email:
example@example.com
Website URL
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Details
Names & Areas of Cities Served
This is for your online listings and directories radius.
Year Founded
Hours of Operation (Sunday-Saturday)
What has been the average of your New Client / New Patient numbers for the past 6 months?
This will be used to benchmark the performance of your marketing in the future.
What has been the average value of your Collections / Gross Revenue for the past 6 months?
This will be used to benchmark the performance of your marketing in the future.
Tagline or Slogan
If you do not have one, please put "N/A".
Would you like to have a Careers Page on your website to promote hiring at your practice?
List of Affiliations/Organizations You Participate In
Please list all businesses and organizations your practice is affiliated with. Organizations should include the proper name and common acronym. If there are none, please enter "none".
About the Practice
Please provide an “About Us” style description of your practice. If you currently have some great content on the “About Us” page on your old website, you may simply want to copy and paste it or provide the link to the website page
Please list any insurance options you accept
If there are none, please enter "none or N/A".
Please list any financing options you offer
If there are none, please enter "none or N/A".
Does the Doctor or Practice have any special awards or certifications we can highlight?
Special Offers/Promotions - If you run any special offers or promotions to attract new clients or incentivize existing clients to make an appointment.
Are You Currently Working With Another Website/Marketing Provider?
Website Details
If you have blogs on your current site, do you own that blog content?
Some website vendors provide “access” to content for your site, but don't actually grant you ownership, or the ability to move that content to a new site. If you're not sure whether you fully own your site content, please contact your current marketing provider or check your contract. Feel free to ask us if you have questions on this.

By selecting "Yes", you are confirming that we are authorized to migrate this content, and that you understand we cannot accept liability for any dispute that might arise with your previous provider with regard to this content.
Do you own the content on your current website, so that it can be migrated to the new site we are building?
This may include written text, images, videos etc.

Some website vendors provide “access” to content for your site, but don't actually grant you ownership, or the ability to move that content to a new site. If you're not sure whether you fully own your site content, please contact your current marketing provider or check your contract. Feel free to ask us if you have questions on this.

By selecting "Yes", you are confirming that we are authorized to migrate this content, and that you understand we cannot accept liability for any dispute that might arise with your previous provider with regard to this content.
Do you use third party scheduling or texting software?
Third-party scheduling software refers to software solutions that allow users to manage and automate the scheduling of events, appointments, and tasks. These tools enable users to create, update, and manage schedules from a centralized platform, often integrating with various other applications to enhance functionality, like your website.

Key features typically include:
- Online Booking: Allows customers to book appointments anytime, anywhere.
- Calendar Integration: Syncs with popular calendar tools like Google Calendar and Outlook.
- Automated Reminders: Reduces missed appointments with email/SMS reminders.
- Payment Gateway Integration: Enables secure online payments for services.
Name of third party scheduling or texting software:
Do you use third party services for any form on your website? (ie. New Patient forms, Request Appointment forms, etc.)*
Do you have “landing pages” or other pages on your website that we would not see by navigating your menus or crawling the site?
For example, some practices have landing pages used for their Google ads which are not in their website menu. If yes, please share links to all these pages so we can ensure they are migrated or handled properly.
Social Accounts
Type a question
Facebook
Twitter/X
Yelp
Pinterest
Bing
Instagram
Google Business
LinkedIn
Apple/ID Maps
NextDoor
Domain Information
Do you have hosted/domain based email?
Current Domain Registrar
A domain registrar is where you purchased your website domain (www.example.com). Common registrars are Godaddy.com, NetworkSolutions.com, etc.
With what provider?
Office 365, Google Workspace, Rackspace, ect
Files Needed
Below is a list of some photos, logos, etc we'll need:
- Logo/Profile Photo File:
  - Photos should be in a square format and anywhere from 180x180 px to 400x400 px size, and of good quality to avoid pixelation. Preferred files types are: Adobe Illustrator, EPS, Vector, JPG.
- Cover Photo:
  - Photos should be anywhere from 820x310 px to 2560x1440 px size, and of good quality to avoid pixelation. If possible, leave enough space around each side to allow for resizing.
- Office Photos:
  - These should show happy clients/patients and the spaces of your office. Waiting areas, reception, exam rooms, etc.
    Gallery Photos
- Gallery Photos
  - Please upload a headshot for each team member so that we can add them to their bios on the site. Make sure to name the image file by the person's name so that we know whose image goes with each bio profile.
- Team Photos
- Style Guide or Brand Book
  - If you have one
File Upload

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Website Intake Form

Office Details

Practice Details

Website Details

Social Accounts

Domain Information

Files Needed

Below is a list of some photos, logos, etc we'll need: