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Optical Website Information Sheet

Company Information

Business Name

Owner's Name

Type of Practice

Ophthalmologist

Optometrist

Optician

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

(Used to validate practice information for SEO purposes)

Phone Number

Fax Number

Company Email Address

Website Information

Do you Have a Website?

Yes

No

If yes, what is the URL?

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

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)

Cross Streets

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.

List the Brands of Designer Frames that you carry:

Would you like pictures of Store / Business?

Yes

No

Would you like Staff Photos on your website?

Yes

No

Please email photos to support@doctorsinternet.com

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

What makes your business special and distinguishes it from your competitors -i.e. How long have you been in business, what special brands do you carry, or do you accept insurances?

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:

A few sentences about the doctor or office:

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Thank You!

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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