Medical Website Information Sheet
Company Information
Practice Name
Owner's Name
Specialty
DEA, Physicians NPl and/or license number(s):
(Used to validate practice information for SEO purposes)
Phone Number
Fax Number
Company Email address
Confirm E-mail
Website Information
Do you Have a Website
Yes
No
What is the URL?
Website Color(s)
Office contact Person for Website Follow Up
Contact's Phone #
Contact's E-mail
Practice/Office Information
Address
City
State
State...
-- UNITED STATES --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
-- CANADA --
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
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 Practice / Office
Yes
No
Staff Photos
Yes
No
Parking Availability / Transportation?
Do you have a parking lot?
Bus Lines
Train Stops
Patient 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..