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49 Colborne St Lower Level Toronto, ON M5E 1C6
+1-888-784-7878
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The Epworth Sleepiness Scale
jingCo websites
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Dentistry Business
>
The Epworth Sleepiness Scale
Step 1 of 5
20%
Congratulations on your new website. We look forward to helping you improve your clinic image and book more patients.
To help us create the website that's right for you and best showcase the feel of your clinic please take a moment to fill out the form below.
If you are unsure of any field please leave it blank. This form is only used to gather preliminary information, we will be in contact with you to gather full feedback.
Full Name
Clinic Name
*
Company Name
Email
Phone Number
Visual Style
What ideas do you have for the style/theme of your website design?
What websites can designers draw inspiration from?
List websites you like and describe what you like about them.
Website address
Example: http://salvaggiodentistry.ca/ (For multiple sites, please separate with a comma)
What do you like about this site?
Is there anything else you would like to communicate to the designers?
Do you have any images, sketches or documents that might be helpful?
Drop files here or
Example: Your current logo, photos, illustrations, content, layout ideas etc.
Images of office and staff you would like to use on the website.
Drop files here or
SERVICES OFFERED
General Dental Services
Broken Tooth
Caps
Cavity
Checkup and Cleaning
Cleaning/Scaling
Crowns
Dental Emergency
Dental Sealants
Extractions/Wisdom Teeth Removal
Fillings
Gum Disease
Nitrous Oxide Sedation
Pediatric Dentistry
Periodontal Therapy
Root Canal Therapy
Sedation Denistry
Sedation Dentistry
Teeth Grinding
Tooth Desensitization
Cosmetic Dental Services
Bridges
Dental Bonding
Gum Reduction
Inlays and Onlays
Teeth Whitening
Veneers
Products
Canker Sores and Cold Sores
Mouthguards
Night Guards
Sleep Apnea
Sports Guards
Thumb Sucking/Snoring Appliances
Special Treatments
Braces
Dentures (Prosthetic)
Headaches
Implants and Bone Grafting
Invisalign (Braces)
Invisible Braces
Orthognathic Surgery
TMJ Disorder Treatment
Preventive Care
Smile Enhancement
Dentistry for Kids
Pediatric Dentistry
Dental FAQs
Top 5 services to promote (in order)
1. 2. 3. 4. 5.
SPECIAL SERVICES OFFERED
Choose among the special services below.
TV during treatment
Music during treatment
Kids Play area
Financing
Wheelchair Accessible
Others (Please specify)
HOURS OF OPERATION
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
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Clinic Hour Notes
PAYMENT METHOD
Choose among the payment methods below.
Cash
Check
Traveler's Check
Invoice
American Express
Diner's Club
Discover
MasterCard
Visa
Financing
Paypal
Payment Plan
Direct Billing
Government Programs
Others (Please specify)
DENTISTS
List the names of the dentists and their bio (you may add it later)
Bio
Name of Dentist
Bio
Name of Dentist
Bio
Name of Dentist
Bio
Name of Dentist
Bio
Name of Dentist
LIST OF STAFFS
List the names of your staffs and their respective positions
Name of Staff
Position
Name of Staff
Position
Name of Staff
Position
Name of Staff
Position
Name of Staff
Position
Additional Staffs (Please enter the name and position)
FEATURE LOGO
Choose among the logos below.
Others (Please specify)
FORMS
Click the form name to see a sample.
Choose forms to be included
Appointment Request
Book Appointment
Confidential Information Questionnaire
Contact us
Dental Referal
Medical Dental History for Adult Patients
Medical Dental History for Patient Under Age 18
New Patient Form
Other (Please specify)
PAGES
Please select pages to be included in your website
Before and After
Financial Information
Office Visits
For Patients
Why Choose Us?
Gallery
Patient Services
Blog
Financing
Booking Request
Book Appointment
Terms of Use
Privacy Policy
Home
About Us
Dental Services
Offers
Contact Us
Pages Under Gallery Page
Office Tour
Smile Gallery
Pages Under Patient Services
Refer a Friend
Programs
Dental Forms
Post Operative Instructions
Pages Under About Us
In the Community
The Team
Reviews
Other (Please specify)
List of emails you want to be created.
ie
[email protected]
,
[email protected]
Do you want us to manage your domain?
*
Yes
No
Not Sure
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