*MEGA* New Client Questionnaire | Medical Websites & Healthcare Marketing

Pre-Live Representative:*

Office Use Only

Carli
Jacob
Zoey
Ryan

Website Address*

Desired launch date?

Additional Website Addresses (if applicable)

Practice & Contact Details

Practice Name*

Practice Phone*

Practice Fax Number

Practice Email*

Practice Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many physical locations does your business have?*

If you have other locations, please provide their address and contact information:

New Website Information

What should the color scheme be?*

You can choose your colors here http://colorpalettes.net/

What look & feel would you like the site to have?

(i.e.: clean, elegant, warm, cutesy, vintage etc)

Theme Choice:*

What are your hours of operation?

Select the Vertical*

Once the vertical is selected, services choices will show below.

Chiropractic Services

Chiropractic Conditions Treated

General Dentistry Services

Cosmetic Dentistry Services

Restorative Dentistry Services

Sedation Dentistry Services

Sleep Apnea
Sleep Dentistry
Special Needs Dentistry
Nitrous Oxide

Pediatric Dentistry Services

General Dermatology Services

Cosmetic Dermatology Services

Dental Technology

Cone Beam 3D Imaging
Digital X-Rays
Intraoral Camera
Laser Dentistry

Medical Dermatology Services

Skin cancer
Mohs Surgey (Basal Cell Cancer)

Medical Services

Optometry Services

Vision Therapy Services

Orthodontic Services

Periodontal Services

Pharmacy Services

Podiatry Services

Custom Orthotics
Surgical Corrections of Foot Disorders

Podiatry Conditions Treated

OB-GYN Services

Which Animals Do You See At Your Practice?

Small Animal Services

Equine Services

Bovine Services

Reproduction
Farm Visits
Surgery

Do you offer any additional services that are not included in the list above?

Online Forms

Use this area to tell us any specific requests for your website.

Are there any specific elements you want included that have not yet been mentioned? Do you want to highlight any particular services, special offers, or other information? Specific requests for the mobile version of your website?

Domain Information

What company did you use to register your domain?*

What is the username for your domain hosting account?*

What is the password for your domain hosting account?*

Are there any emails associated with your domain name ([email protected])? Please list them all below:

If yes, how do you access them? (ex. Through the website, gsuite, Microsoft Outlook, etc.)

Which of these social media pages does the hospital have?

Facebook
Instagram
Twitter
Google My Business

Phone

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

Practice & Contact Details

New Website Information

Domain Information

Contact Info

Important Links