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Medical Website Information Sheet

Company Information

Practice Name

Owner's Name

Specialty

DEA, Physicians NPI and/or license number(s):

Phone Number

Fax Number

Company Email Address

Website Information

Do you Have a Website?

Yes

No

Do you own the current content and or website?

Yes

No

What website style you would like?

Kraken Polished and professional

View Example

Gorgon Sleek and captivating

View Example

Phoenix Fresh and youthful

View Example

Hydra Contemporary and stylish

View Example

Manticore Bold and modern

View Example

Basilisk Vibrant and playful

View Example

Griffin Clean and focused

View Example

Pegasus Sharp and professional

View Example

Yeti Modern and engaging

View Example

What website style you would like?

Website Color(s)

Office contact Person for Website Follow Up

Contact's Phone #

Contact's E-mail

Practice/Office Information

Address

City

State

Zip

Neighborhood Name(If Any)

Business Hours:

Sunday:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Payment form accepted:

Visa/Mastercard

American Express

Discover Card

Personal Check

Cash

Other:

Insurances Accepted:

Service & Information

Top 5 Services or Products Provided:

1.

2.

3.

4.

5.

Other Services:

Would you like pictures of Store / Business?

Yes

No

Would you like Staff Photos on your website?

Yes

No

Parking Availability / Transportation

Parking Availability / Transportation?

Do you have a parking lot?

Bus Lines?

Train Stops?

Customer Demographics (for selecting website photos)

Neighborhoods / Zip Codes serviced by your business

DOCTOR BIO / STAFF

Staff Members to appear on Website:

1.

2.

3.

4.

5.

Doctor's Bio

Education - School and year of Graduation:

Degree:

Years at Current Practice:

Awards/Certificates:

Associations:

Publications:

Outside Hobbies / Recreations:

Bio:

Please write a few sentences or points below about what you would like to stress about your practice on your website. Such points can be for example, new technologies, that your office will work with many insurances, or that you have been in the same location for many years, etc...

I have read and filled out all the available information for this questionnaire

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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