Practice Information

Exact Practice Name:

Please list the practice name as it appears on signage and storefront.

Primary Website Domain URL:

Please list your primary website domain (www.YourPractice.com).

Primary Office Email Address

This is generally the email address used for patient correspondence.

Main Office Telephone Number:

This would be the public facing (local) telephone number of your practice.

Exact Practice Address (Please Include Suite Numbers if Applicable):

Address Line 1

Address Line 2

City

State

Zip Code

When Did Your Practice Open (Month & Year)?

Open Business Hours:

Please list the hours your business is open.

Doctor(s) Names:

Please list all doctors practicing at this location separated by commas.

How Long Have The Doctors Been in Practice:

Please list how long each doctor has been practicing.

Please list any dental associations your practice belongs to (AACD, ADA, State Level Associations, etc.):

Has the practice or doctors won any awards? If so, please list them all here.

This could be things like "People's Choice" or "Voted Top Dentist in State by..."

Languages Spoken At The Office:

Please list any languages spoken at the office.

If You Offer Financing Options, Please Explain Your Available Options Here:

Please provide as much detail on 3rd party vendors or in office financing options here.

Major Insurances Accepted (if too many to list, you can send at a later date):

What is a new patient worth to your practice (dollar amount)?

Please include any other URL's that your practice owns:

Please list any other domains or websites that YOU OWN that could possibly be associated with the practice (such as: www.IndivdualDoctorsName.com).

Do You Use Any Microsoft Outlook Products for Email?

Please let us know if you use Microsoft Outlook for office emails as we will need to update some settings within your Outlook.

Are You Currently Marketing for New Patients?