PatientPoint | Launch - Website Intake Form

Website Intake Form

We look forward to building your branded website! Please provide as many details as possible about your business.

If you would like to gather this information and submit the intake form at a later time, please download the following intake form checklist: Website Information Form
Contact Information
Please provide the Personal Contact Information of the main contact for this website project.
Name:*
Email:*
Phone Number:*
Business or Practice Contact Information
Business Name:*
Business Email:*
Business Phone Number:*
Business Fax Number:
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hours of Operation (Please list your hours of operation and closure schedule if applicable)*
Website Domain
Do you currently have a website?

YesNo
Please enter your website address and login credentials below. Please feel free to email these directly to websites@patientpoint.com if you don't have them at this time. *Note: we will need access to your domain account prior to launching your website
Website Address: (Ex: www.mywebsitename.com)
Domain Provider (i.e. GoDaddy, DomainCheap, eNom, etc.)
Account Number:
Account Password:
What would you like your domain name to be? Please visit GoDaddy.com to select a suitable domain, or we can provide you with options.
With PatientPoint Launch, we provide 2 branded emails with your website. What would you like your emails to be? Please enter 2. (i.e. info@mypractice.com, drsmith@drjohnsmith.com, contact@mywebsite.com)*
*For additional emails, our hosting fee is $7.50/email per month.
Do you have domain-based emails such as info@mydomain.com?*

YesNo
If yes, how many email addresses do you currently have?
Website Information
Do you have a logo?

YesNo
Please upload your logo file(s) here

Upload a File

Cancelof
Would you like us to use your logo colors in the website design?

YesNo
Please select a primary color from www.colorpicker.com and enter the color # below
*www.colorpicker.com
Please give us a brief overview of the following
Please write a brief paragraph describing your business ("About Us" section):*
List Your Services:*
Provider/Staff Information (Please include the name, title and bio for each provider/staff you would like to include on the website. To upload a document with this information, please use the upload tool below.)
Provider/Staff Information (File Upload)

Upload a File

Cancelof
Provider/Staff Headshots (If applicable, please provide a headshot for each provider/staff member included above)

Upload a File

Cancelof
Please include any additional details you would like to add to your website or any information you would like us to know (i.e. new patient forms, patient resources, social media links, etc.):
Should be Empty:

Contact Information

Business or Practice Contact Information

Website Domain

Website Information