New Client Intake — PMAX Dental

Step 1

Contact Information

Who we should talk to about this project.

PRIMARY Contact Name

PRIMARY Contact Phone #

PRIMARY Contact Email

List Additional Contacts Here

NameList Additional Contacts Here — Name, row 1
Phone #List Additional Contacts Here — Phone #, row 1
EmailList Additional Contacts Here — Email, row 1

Practice Information

The basics about your practice. We have filled in what we could find on your website.

Practice NAME

Primary Practice FOCUS

Location(s)

AddressLocation(s) — Address, row 1
Phone #Location(s) — Phone #, row 1

Office Hours

DayOffice Hours — Day, row 1
HoursOffice Hours — Hours, row 1

One row per day, as we read them off your site. Edit any day, or add rows for days we missed.

TARGET AREAS — cities you want to attract patients from

City / AreaTARGET AREAS — cities you want to attract patients from — City / Area, row 1

We have added the city from your address. Add any other cities or areas you want to target.

Do you offer any UNIQUE SERVICES others don't?

What AWARDS/ACCOLADES has your practice received?

Who would you consider to be your TOP COMPETITORS?

CompetitorWho would you consider to be your TOP COMPETITORS? — Competitor, row 1

Nearby practices we found on Google Maps. Remove any you don't consider competitors, and add others.

Is there a practice SLOGAN, MOTTO, MISSION or MAIN FOCUS?

What type of patients are you trying to attract/target?

Do you belong to any DENTAL ORGANIZATIONS?

ValueDo you belong to any DENTAL ORGANIZATIONS? — Value, row 1

Step 2

Website & Domain Information

Web ADDRESS

Do you own the DOMAIN?

YesNoUnsure

Domain REGISTRAR

Who the domain is registered with. Read from the public domain registry — correct it if it has moved.

Domain EXPIRES

When the domain registration lapses, from the public registry. Renew before this date to keep the site online.

Where is your website HOSTED?

Do you use EMAIL associated with your domain?

YesNoUnsure

Who provides that email?

Read from the domain's MX records. Correct it if it has moved.

If yes, please list email addresses below.

ValueIf yes, please list email addresses below. — Value, row 1

Do you have any call tracking/forwarding numbers that we should be aware of?

YesNoUnsure

Social media profiles

PlatformSocial media profiles — Platform, row 1
URLSocial media profiles — URL, row 1

The profiles we found linked from your site. Correct any that are wrong and add the ones we missed.

No domain login needed right now. We only need registrar access closer to launching your new website — it would help if you could have those details ready for us nearer the time, and we will arrange a secure way to share them when we get there. The following fields from our older form are intentionally omitted: DOMAIN Username (Login for GoDaddy, 1and1, etc.), DOMAIN Password.

Step 3

Your New Website

Please list your top services/products in order of priority below.

ServicePlease list your top services/products in order of priority below. — Service, row 1

Most important first — drag the handle, or use the arrow buttons. We have listed what we found on your site.

Do you need any pages deleted or added?

0 pages carrying over

Keep row 1

This is your current sitemap as we found it. Untick anything that should not carry over, and add pages you want.

Are there any brand materials already in existence that we need to match or coordinate with? Any colors, typefaces we must use?

What EMAIL(s) would you like your new contact forms to be delivered to?

ValueWhat EMAIL(s) would you like your new contact forms to be delivered to? — Value, row 1

Step 4

Comments/Questions

Is there any ADDITIONAL information you would like us to know for your new website?