Website Questionnaire
YOUR PRACTICE
Practice Name:
Practice Address
City
State
Postal code
Practice Phone Number:
Practice Email:
Website Domain (if you have one):
Year your practice was established:
Practice Hours of Operation:
Languages spoken in your office:
YOUR TEAM: DENTIST
About the Dentist: (Name, info, hobbies)
Why did you choose to become a dentist?
Do you have any advanced training in specific dental specialties? How many continuing education credits do you complete each year? Are they in specific types of services?
Professional organizations and affiliations:
Community/Charity involvement that we can mention by name:
Personal hobbies/family pastimes:
YOUR TEAM: STAFF
Who are your team members? (Name, role, bIo)
YOUR PATIENTS
Who is your ideal audience? Any patients you prefer not to treat? (Kids, individuals with special needs, etc.)
What sets your practice apart from the competition? Why should they choose your practice?
Describe your “gold standard” patient experience that your team provides.
What typically happens during the first patient appointment? Walk us through it. (Who will they see: You or the hygienist? ...how long will it take? ...patient experience/environment?)
Amenities offered: (TV in operatory, headphones, warm blankets)
YOUR SERVICES
TOP 3 Procedures you would like to perform more often:
What equipment have you invested in? Examples: Digital X-rays, LANAP, Advanced OCS tools, CEREC, Biolase, CBCT, Itero
FINANCING
Membership Program: Give details
In-Network Insurance Options
Out-of-Network Insurance Options: Do you accept out-of-network plans?
Financing Options: (3rd party or in-office, special offers to mention)
Please include links to your patient financing options.
Do you accept Medicaid?
Yes
No
Do you accept Medicare?
Yes
No
Does your office have any special offers and promotions?
Other Notes
Do you have a self-booking link? If yes, insert link here.
Do you have a new patient online forms link? If yes, insert link here.
FAQs to Mention:
Other Notes:
Your First Name
*
Last Name
*
Email
*
Phone
*
