Practice Contact Information

First Name

Last Name

Practice Name

Practice Code

Email

Practice Website URL (If you don't have a website, please indicate so.)

Location Information

City / Town

What specific neighbourhoods / areas do you serve? (downtown, west, etc.)

Are there any well-known landmarks nearby? (buildings, intersections, etc.)

Dentist Information

What types of dentists and specialists work in your Practice? Select all that apply:

General Dentist

Pediatric Dentist

Prosthodontist

Periodontist

Orthodontist

Endodontist

Oral/Maxillofacial Surgeon

Anesthesiologist

Other

Please lists the names of the General Dentists (Dr. FirstName LastName)

Please lists the names of the Specialists and Speciality (Dr. FirstName LastName, Speciality)

Team Information

Please lists the names of the Dental Hygienists (FirstName LastName)

Please lists the names of the Dental Assistants (FirstName LastName)

Please lists the names of the Administrative Staff (FirstName LastName)

About Your Practice

Please tell us about your practice.

Current Office Hours

Languages Spoken at Your Practice

Office & Reception

Comfortable Seating

Children’s Play Area

Entertainment (TV)

Entertainment (iPad)

Other

If other, please specify.

Location, Parking & Accessibility

Convenient Location

Accessible by Public Transit

Convenient FREE Parking

Convenient PAID Parking

Wheelchair Accessible

Other

If other, please specify.

Patient Experience:

Same-day Appointments

Quick Check-up Appointments

Multiple Appointment Bookings for Families

Online Booking

Short Wait Times

Automated Appointment Reminders

Phone Call Appointment Reminders

Other

If other, please specify.

Is there anything else you'd like to add about your practice?

Financing & Insurance

Financing Options

DentAssure

Other

None

If other, please specify.

Payment Methods

Cash

Cheque

Debit

Credit Card

Other

Do you offer direct billing to insurance companies?

If you do not offer direct billing, do you submit insurance claims on a patient's behalf?

Other Financial & Insurance Details

Services Offered

From the list below, please check off all the services you provide.

Preventive Dental Hygiene

Hygiene Cleanings

Oral Examinations

Oral Cancer Screening

Fluoride Treatment

None

Other

If other preventive services, please specify.

Restorative Dental Services

If other restorative services, please specify.

Cosmetic Dental Services

Teeth Whitening

Veneers

Lumineers

Dental Bonding

Full-Mouth Restoration

None

Other

If other cosmetic services, please specify

Oral Surgery

Dental Implants

Extractions

Wisdom Teeth Removal

Frenectomy

Gum Graft

Bone Grafts

Sinus Lifts

None

Other

If other oral surgery services, please specify.

Orthodontics

Braces - Metal

Braces - Ceramic

Braces - Lingual

Clear Aligners - Invisalign

Clear Aligners - Other brand (please specify below)

None

Other

If other orthodontics services, please specify.

Dental Appliances

Night Guards

Sports Guards

Snoring Oral Appliances

Sleep Apnea Oral Appliances

CPAP Machines

None

Other

If other appliances, please specify.

Dental Sedation

Nitrous Oxide

Oral Sedation

IV Sedation

General Anesthesia

None

Other

If other sedation services, please specify.

Additional Services

Children

Emergencies

None

Other

If other additional services, please specify.

What are the top 5 services you would like to promote on your website?

Dental Technology

Please select the technologies that you use at your practice

If other, please specify.

Practice Personality & 'Voice"

Do you have a motto, tagline or catchphrase that you would like to see on the website? If so, please provide it here.

Do you prefer emotive language or objective language? For example, "We love caring for the smiles of our community" (emotive) vs. "We're here to keep your teeth healthy" (objective)

Emotive

Objective

A balance of both

Do you have a preference about the use of contractions? (“We’re accepting new patients” vs. “We are accepting new patients”)

Contractions are fine

Please don't use contractions

Keep contractions to a minimum

Anything else you would like us to know about how you want your practice brand portrayed online?

Patient Demographics

To help inform the types of images we'll use on your website, please provide some demographic details about your patients.

Patient Types (singles, families with children, young professionals, seniors etc.)

Ethnicities (Caucasian, South Asian, Chinese, Black, Latino, etc.)

Are there any demographics that you would like to market to more strongly on your website?

Social Media

If you have any social media accounts you would like your new website to link to, please provide the links below.

Facebook

Instagram

Twitter

Other

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Practice Contact Information

Location Information

Dentist Information

Team Information

About Your Practice

Financing & Insurance

Services Offered

Dental Technology

Practice Personality & 'Voice"

Patient Demographics

Social Media

Your Current Website

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