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Website Design Brief

Get started on your new website today!

Please take a moment to complete the following questionnaire regarding your brand. Please complete as many questions as possible.


Practice Name:
Doctor's First Name:
Last Name:
Street Address 1:
Street Address 2:
Emergency / After Hours Phone:
Email Address:
Your Consultant:
Office Contact:


Favorite Site Name:
Other Site Names you like / Notes:


Call to action:

A call to action is the next step you want a visitor to your website to take. A call to action could be as simple as "call and make your appointment today!" or "Ask us about our free whitening offer!".

Office Hours:







Other Hours:

A map and link to online directions will be provided on your website. Please enter any additional directions (i.e. major roads or landmarks) to your office in the space below:

Domain Name:
  • Do you already own a domain name?
  • YES, my domain name is: www.
  • NO, I will register a web address and provide it to Dental Branding.

Dentrix and Easy Dental customers, please contact eCentral for assistance in registering your domain name.

Include any additional information that you think would be helpful:
Select the services you offer:
  • Bonding
  • Bridges
  • Crowns
  • Dental Cleaning
  • Dentures
  • Extractions
  • Fillings
  • Gum Treatments
  • Implant Placement
  • Implant Restoration
  • Invisalign
  • IV Sedation
  • Mouth Guards
  • Nitrous Oxide Sedation
  • Oral Sedation
  • Orthodontics
  • Root Canal
  • Sealants
  • TMJ Treatment
  • Veneers
  • Whitening
  • Wisdom Teeth
  • Other Services:
Select the technologies you offer:
  • Air Abrasion
  • Aqua Abrasion
  • Auto Appt Reminders
  • Cavity Detection Technology
  • Computerized Shade Matching
  • DiagnoDent
  • Digital Imaging
  • Digital X-rays
  • Electronic Claims
  • Film X-rays
  • Intraoral Camera
  • Laser Dentistry
  • Paperless Charting
  • Patient Education
  • Same-Day Crowns
  • Telescopic Loupe
  • Other Technology:
Select the payment options you accept:
  • Cash
  • Discover
  • Visa
  • Citi Health
  • Chase Health Advance
  • Discounts
  • Check
  • Major Insurance
  • Participating Insurance
  • Master Card
  • Capital One
  • Money Order
  • CareCredit
  • In-house Payment Plans
  • American Express
  • Wells Fargo
  • Other Payment Type(s):

By clicking on “I Agree” I understand the timeline involved in completing my Responsive Website and agree to the terms and conditions. Dental Branding will post an initial design option within 5 business days of receipt of payment and initial site consultation. I have up to 3 revisions on the designs, and after the third revision the site will be built. After my initial site consultation, I will have 8 days to deliver any custom content I want on the site. Once my site is posted for initial review, I will have 3 days to make changes before the site goes live. After the site is posted live I will have an additional 2 hours of design time to make any further modifications.

Terms and Conditions I Agree (type your initials to confirm)