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DMM Client Intake
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DMM Client Intake
Full Name
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Email Address
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Phone Number
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Best Time to Contact
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DMM Client Intake Questionnaire
--- Select a Section to Fill ---
1. Practice & Contact Details
2. Specialty & Patient Services
3. Branding & Design Preferences
4. Website Content & Features
5. Marketing & SEO
Legal Business Name
DBA / Brand Name
Primary Contact Name & Title
Practice Address(es)
Existing Website URL
Year Established
Tax ID / NPI Number
Authorized Decision-Maker
Healthcare Entity Type
Solo Practice
Group Practice
Clinic
Hospital
ABA Center
Telehealth
Other
Primary Medical Specialty
Accepting New Patients?
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Yes
No
Limited
Offer Telehealth Services?
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Yes
No
Accepted Insurance Providers
States Licensed to Practice
Number of Providers
Logo Style Preference
Wordmark
Icon + Text
Monogram
Symbol Only
Not Sure
Feelings Logo Should Evoke
Colors you LOVE
Colors you HATE
Website Visual Style
Modern/Minimalist
Warm/Welcoming
Clinical/Professional
Bold/Confident
Luxurious
Do you have professional photography?
*
Yes
No
Some
Pages Needed
Home
About Us
Provider Bios
Services
Patient Resources
Contact
FAQ
Features Needed
Online Booking
HIPAA Forms
Patient Portal
Telehealth Integration
Online Bill Pay
Scheduling Software Used
EHR/EMR System Used
Target Keywords
Target Cities for Search
Google Business Profile Claimed?
*
Yes
No
Top 3-5 Competitors
Marketing Consent
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By providing your contact information, you agree to receive marketing communications from our business via text messages and phone calls. You understand and agree that these communications may be made using automated dialing systems, pre-recorded messages, or AI-generated voice technology. Calls and messages may be delivered between 8:00 a.m. and 6:00 p.m. You may opt out of future communications at any time by replying STOP to any text message or by following the opt-out instructions provided during a phone call. Consent is not a condition of purchase.
Promotional Consent
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By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.
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