Contact Information (for our use only)

    Doctor Name:

    Office Number:

    Cell Number:

    Direct Email Address:

    Your date of birth (mm/dd):

    Best meeting days & times:

    How did you hear about Identity Dental Marketing?

    Which of the following applies to you?
    We have an established practice.We are moving to a new location.We are opening an additional location.I recently purchased a practice.I am starting up a practice.

    Existing Website (optional - listing information from an existing website will allow us to attain much of the information from below quickly and easily):

    Do you have rights to reuse any of your current website's written content?:
    YesNoI don't have a current website

    Involved Team Members

    Please provide us the name, email & title of employees who you would like us to interact with for marketing, payments, scheduling meetings, etc.

    Employee #1
    Name:

    Title:

    Email:

    This employee is responsible for:MarketingPaymentsScheduling Meetings
    Other:

    Employee #2
    Name:

    Title:

    Email:

    This employee is responsible for:MarketingPaymentsScheduling Meetings
    Other:

    Contact Information for Website

    Your name as it should appear on the website (i.e. Johnathan N. Smith, D.D.S.):

    Your nickname as it should appear on the website (i.e. Dr. John):

    Practice name as it should appear on the website:

    Address of office, including suite number if applicable:

    Phone number:

    Email address for online inquiries and website contact forms:

    Landmarks or directions you’d like to include: (Example: We’re located at the corner of Green St. and Maple Ave. next to the Animal Hospital.):

    What are your office hours?:

    Do you offer any special amenities (coffee, blankets, ipad use, etc) or services (multi-lingual staff, same-day appointments, in-house benefits plan, etc) that make your practice stand out?:

    Branding

    Please upload your logo if we do not already have it for use in your website design. (Optional)

    What colors do you prefer/dislike?

    Please select up to 5 selling points you wish to highlight on your new website's homepage:

    Comprehensive dentistryFamily dentistryImplant dentistryCosmetic dentistrySleep apnea treatmentConvenient hoursSame day dentistryComfortable officeAdvanced technologyEducation and experiencePersonalized careFlexible payment optionsFriendly team

    Other:

    Website Content

    Do you prefer your website to be written from 3rd person (Dr. Dentist and his/her team... They are...) or 1st person team member perspective (Dr. Dentist and our team... We are...)?

    Select services that you would like listed on your website:
    PreventiveCosmeticRestorativeChildren'sPeriodonticsOrthodonticsEndodonticsSedationSleep Apnea TreatmentTMJ/TMD Treatment

    Other:

    Please select any technologies you would like featured on your website:

    Digital X-raysIntra-oral CameraCERECE4DCone Beam CTPanoramic X-raysVELscopeCavitronSoft Tissue Laser

    Other:

    Select from the following:

    Please select from the following:


    Other:

    How many years of experience do you have?

    Where did you attend dental school? Undergraduate?

    Are you a member of any dental associations? If so, please list them.

    If you’d like to include information about your team, please provide it here or or email team biographies to dixie@identitydental.com: (You can also send us a link to existing biographies from an existing website where we can pull information.) This information can also be added very easily later through your CMS (content management system).

    Please list your financial policies/insurance information to be included on the website:

    Do you offer any new patient specials? (We recommend this.) If you’d like to include this information on the website, please post it below:

    Would you like to include a testimonials page, where your patients can write and submit reviews directly to your website? (no extra charge):

    Current Website and Email Hosting

    Where are your current website hosting and domain services?

    Will you need email hosting upon launching your website? If so, please list the email addresses you currently use associated with your domain name. (example: info@yourwebsite.com)

    Do you have multiple domain names that you would like us to forward to your main domain name? (optional)

    Social Media Links

    Link to Facebook page (Optional) :

    Link to LinkedIn page (Optional) :

    Link to Twitter page (Optional) :

    Link to G+ page (Optional) :

    Other integration information

    Some practices have a 3rd party system, (like Dentrix Login for patients or DemandForce for scheduling) that they’d like to include integration. Please include the embed code or links for these services. If you do not know how to attain this information, we’re happy to guide you through this process. Just ask.

    Stock photography

    Which demographics would you like included on your website? Please include information on age and nationality of your target market.

    Attachments

    Please attach and email the following documents (optional) :

    • Patient forms available for download
    • Team Bio’s
    • Team photo(s) & doctor headshots
    • Before & After photos
    • Office photos

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    Add file

    Additional files or website requests can be sent to natalie@identitydental.com. In the Subject Line of your email, please include your practice name.