In order for us to build a web site that accurately reflects the unique qualities of your practice, we need to obtain as much information as possible. This questionnaire is designed to give us a jump start on the process! Please fill it out with as much detail as possible.

* Your Contact Person: * Name of Doctor(s): * Street Address: Street Address 2: * Town/City: * State/Province: * Country: * ZIP/Postal Code: * Phone (include area code): * E-mail (very important!): 1. Which category below best desrcibes your practice? Check all that apply. Primarily Cosmetic Family Practice Senior Emphasis Kids Emphasis Specialist Other * 2. Please list web sites that contain elements that you’d like to have on your site? What features in these sites appeal to you? Site #1 http:// What do you like about this site? Site #2 http:// What do you like about this site? Site #3 http:// What do you like about this site? 3. Do you have an existing web site? Yes No If yes, what is the URL? http:// 4. Have you already registered a domain name, but don’t have a web site yet? Yes No If yes, what is the domain name? 5. Would you like Electro Art, LLC to recommend an ISP to host your site? Yes No * 6. Web Site Sections - Please check all sections you would like to include in your site: Our Office Our Services About Our Doctor(s) Office Tour (text and still images only) Payment Options Office Hours and Location Aesthetic Solutions Galleries (before and after) Our Staff Contact Us Testimonials Other: Other: Other: Other: Please check all sections you would like to include in your site - (for an additional fee). Patient Education (CAESY.com) Oral Pathology Guides (CAESY.com) Patient Forms SmileLink Patient Newsletter (CAESY.com) 7. Do you have a logo? Yes No If yes, is it in electronic format? Yes No 8. Do you have all the photos you want to include for your office? Yes No If yes, how many photos do you have? Will you need them to be scanned? Yes No 9. Do you have any established colors you’d like to use in your web site? Yes No If yes, what are the colors? Color 1: Color 2: Color 3: Color 4: Color 5: Color 6: 10. Do you have any established typefaces (fonts) you’d like to incorporate into your site? Yes No If yes, what are they? Font 1: Font 2: Font 3: Font 4: 11. Do you have materials (brochure, handouts) that show information, photos, colors, typefaces or anything else to convey your ideas? Yes No If yes, do you have them in electronic format? Yes No 12. Please state three dates and times that would be convenient for you to participate in the 30-60 minute design consultation (include time zone information): Option 1: Option 2: Option 3: Additional Comments: By submitting this questionnaire I authorize Electro Art, LLC to proceed with my design consultation.