New Client Questionnaire New Client Questionnaire Please fill out this form, if you have any questions please call us at (888)-611-8279. If you do not have the answer to any question right now, go ahead and enter N/A to continue to the next. Step 1 of 2 50% Here are a couple of tips regarding the New Client Questionnaire form that will allow you to bypass required fields in case you do not have the requested information: If there is an item that you do not have at this time please put "N/A" in the field. If the field requires a URL or web address and you do not have that information at this time, please place "none@none.com" in the field. Primary Contact Name* First Last Primary Contact Email* Secondary Contact Name First Last Secondary Contact Email PhoneYour Website URL* Current Site InformationWe will need the information for where your current domain is in order to place your site live. This is where your domain xyz.com was purchased.Are you currently in contract with a Marketing company other than Crystal Clear Digital Marketing (CCDM)?*YesNoIf yes - Expiration Date of Current Contract Date Format: MM slash DD slash YYYY Current Domain Registrar*Name/URL (GoDaddy, BlueHost, Register.com, or wherever you purchased your URL).Current Website Domain Username*Current Website Domain Password*Domain Based Email*If you have a domain based email please provide here. An example of a domain based email is info@crystalcleardm.com where the website address is the email extension. Back-end Access Name/URL (Wordpress, Wix, Squarespace, etc.)Current Website Username*Current Website Password*Google Analytics AccessWe would like to be able to use your existing analytics account so we have some historical reference. You can either add us as a admin user, or simply provide us the login and we will go in and make ourselves admins. The email to enter to give us access is seo@crystalcleardm.com. Current Google Analytics EmailCurrent Google Analytics PasswordGoogle My Business AccessWe would like to be able to access your current Google My Business account so we can correctly configure your account and optimize your practice location for maximum SEO benefit. Current Google My Business EmailCurrent Google My Business PasswordDo you use RealSelf? Yes No We have an integration to capture phone calls and forms into our software system.Social Media AccessIf you do not currently have any of the following accounts, please create new accounts and add login credentials below.Facebook Email*Facebook Password*Twitter Email*Twitter Password*LinkedIn Email*We need access to you personal LinkedIn profile if a company page has not been created. If you do not have a company page, we can create one for you.LinkedIn Password*Pinterest Email*Pinterest Password*Location(s)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have multiple office locations?YesNoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Still have more office locations?YesNoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Direct Phone Number*Do you have more than one practice number/location number?YesNoPlease list any additional phone numbers below.If you have multiple locations with different numbers, please specify. Top 4-8 Revenue Making ServicesList in order of importance.Share more information about your practiceNumber of Employees & Number of patients, etcList of doctors/staff that will need access to the Social Patient Center (SPC)Software & Training - Full Name, Email Address & TitleWhere would you like your form submissions from the website to be emailed to?*Please list the email(s) you would like notifications to go to from the software system.What domain based email would you prefer as your "from" sending email?* This is the "from" email that will display when emails are sent to your patients from the software system.Logo Files Drop files here or Please provide us with a high quality version of your logo. What we need is an EPS, AI, PNG, or PSD. If it is PNG or PSD it should be 1280X720. This will help us in buiulding the website and your overview video.Practice Images Drop files here or We would love to be able to have high quality images of 1280X720 of the doctor(s) and/or the staff. If you have these images on the website, you can skip. This will help us in buiulding the website and your overview video.Staff Images Drop files here or We would love to be able to have high quality images of the staff.Name of person filling out this form. First Last The information provided is accurate as of this date it is submitted.
