New Client Intake Form
Client Number
Sales Person
Contract Start Date
MM slash DD slash YYYY
Core Products
Add-On Products/Services
Contract End Date
MM slash DD slash YYYY
Website Development (if selected must choose one below)
Premium Package (NEW DEV)
Pro Package (TEMPLATE)
Essential Package (TAKEOVER)
Patient Scheduling Pkg (if selected must choose one below)
(NPS) New Patient Scheduling (lead mgt, new patient only)
(RPS) Rollover Patient Scheduling (call overflow scheduling only)
ROI Software (if selected must choose one below)
(Pkg A) Analytics Only
(Pkg B) Analytics and Lead Mgmt)
Add-On Products/Services
Social Media Pkg (Blog, soc postings only)
Online Reputation Mgmt. Pkg (24/7 rep monitor, notification,rep)
Retention Suite Pkg (Survey, Appt. Reminders, ORM, LCM)
PPC Marketing Pkg (media plan/campaign mgmt./reporting)
Creative & SEO Pkg
Premium Package (5hr - 2 creative, 1 event)
Essential Package (5hr - 1 creative)
Value Package (2hr – edits only)
Contract End Date
MM slash DD slash YYYY
Client Location and Contact Information
Business Name:
Industry/Specialty:
Anti-aging
Bariatrics
Dentistry
Dermatology
Ear Nose Throat
Hair Restoration
Home Health Care
Hospital
Lasiks
Medical Spa
Multi-Specialty Group
Orthodontics
Other
Pain Management
Plastic Surgery
Vascular Surgery
Wellness and Recovery
Does client require Lead Management services?
Yes
No
Is the PMR/EMR cloud or server based?
Server
Cloud
PMR/EMR system is used for Scheduling ?
PMR/EMR system is used for Revenue?
Business Owner(s) Name:
Title:
Direct Phone:
Mobile Phone:
Email:
Business Owner(s) Name:
Title:
Direct Phone:
Mobile Phone:
Email:
Is this a multi-provider business?
Yes
No
Total Physicians:
1
2
3
4
If yes, please list all other providers:
Specialty:
Key Staff Contacts / Launch Call Contact
IT Technical Contact Name:
Title:
Phone:
Email:
Office Mgr/Project Lead Name:
Title:
Phone:
Email:
Business Location(s)
List all location addresses below:
How many locations does the client have?
1
2
3
Street Address
City
State
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Zip
Service Area: ( ex. Atlanta, Buckhead, Marietta)
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Days:
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Cities to include for website optimization: (Within 10 Miles Of Office)
Website Technical Information
Number of websites to build for client:
1
2
3
If more than 1 please list URL and explain reason(s) for additional sites:
URL:
Reason:
List Domain(s) that we will be hosting:
Current Domain Authority:
Current Domain Speed:
Current Domain Authority:
Current Domain Speed:
New domain required?
Yes
No
URL of new domain to be created/hosted:
List additional URLs or Websites that the business has:
Foreign Language required for any sites?
Yes
No
Select Language(s) required
Spanish
French
Other
Current Web Hosting
Company Name
Contact Name
Log-In
Email
Password
Phone
Secret Link
