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New Client Form
Please complete this form to reduce any errors.
19
Questions
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1
YOU NAME
*
This field is required.
First Name
Last Name
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2
YOUR EMAIL
example@example.com
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3
MOBILE NUMBER
What is your mobile number?
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4
COMMUNICATION COMPLIANCE
*
This field is required.
Your practice and members agree to accept communications via Email and SMS relating to our services, project developments, ongoing support, new services, billing, and event reminders.
YES
NO
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5
PRACTICE NAME
if different to your name
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6
PRACTICE TELEPHONE
*
This field is required.
The primary number you want on your website
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7
PRACTICE ADDRESS
*
This field is required.
if you have more than one address, list your main address
Street Address
Street Address Line 2
City
State
Postal Code
Australia
Australia
Australia
Country
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8
DO YOU HAVE A CURRENT WEBSITE?
*
This field is required.
YES
NO
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9
WHAT IS YOUR WEBSITE ADDRESS (DOMAIN)
A domain or URL - eg: www.practicename.com.au
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10
DO YOU REQUIRE A NEW DOMAIN?
*
This field is required.
YES
NO
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11
DO YOU HAVE A PREFERRED DOMAIN?
We can arrange a domain it it is available
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12
YOUR AUSTRALIAN BUSINESS NUMBER (ABN)?
To register a domain we will need your ABN, please supply your ABN - link: https://abr.business.gov.au/
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13
WHAT ARE YOUR OPEN HOURS?
*
This field is required.
Please advise your opening and closing times
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
PUBLIC HOLIDAYS
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14
WHAT IS YOUR WEBSITE'S PURPOSE?
*
This field is required.
Define your new website's primary purpose or outcome?
Tell Visitors Who You Are
Be Found via Name Search
Be Found for a Condition Search
Provide Information to Patients
Drive Practice Efficiency
Attract New Patients
Define Your Treatment Niche
Promote a Professional Image
Build a Niche Authority
Promote Competitive Advantage
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15
LIST ALL HOSPITAL LOCATIONS?
List other locations to be featured on the website
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16
WHAT IS YOUR CLINICAL FOCUS?
In order of priority what are the most important clinical topics you want your website to address?
Please help us understand what the highest-priority conditions you treat are and what specific treatments you perform.
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17
WHAT OTHER KEY ELEMENTS ARE REQUIRED?
Please advise on any other key elements your require for the website
Examples: New Patient Form, Pre-Op Forms, Privacy or Consent Policies, First Visit, Your Technology, Your Approach, Your Team etc
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18
LIST ALL OTHER OTHER CONSULTING LOCATIONS?
List other locations to be featured on the website
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19
THANK YOU
*
This field is required.
All information is strictly private and is only viewed by our company. The content is not shared or sold. Please refer to our
PRIVACY POLICY.
We reserve the right to delay the commencement of website development until we have the complete brief and details needed to design your site. By submitting this New Client Form I agree to our
Terms of Service
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