Website Enrollment

  1. Practice Information

  2. Practice name:
    Practice specialty:
    Main address:
    City: State: Zip:
    Phone:
    Fax:



  3. Website Preferences

  4. Current website address (if any):

    Preferred website address: www..com

    TIP: We recommend matching your practice name and keeping it simple, e.g., abcpractice.com. We can help you select a website address.

    Design Packages


    Service Packages





  5. Contact Person for Website Construction Process

  6. Contact name:
    Title:
    Phone: Ext.:
    Fax*:
    E-mail*:
    Address:
    City: State: Zip:

    *E-mail and fax are required. Our communication is conducted via e-mail, and secondarily by fax. We do not give your contact information to other businesses without your permission.


  7. Person Completing Form (if different from above)

  8. Name:
    Title:
    Phone: Ext.:
    E-mail:



  9. How Did You Hear About Us?

  10. Web search:     Google     AOL     Other search engine
    Direct mail
    Ad on a health information website published by Healthcommunities.com
    Link from another website:
    Referred by another practice:
    Other:



  11. Website Service Agreement



  12. Appointment Request Form Service Agreement



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before clicking "Sign Up."

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WHAT HAPPENS NEXT?

  1. We will contact you by phone to arrange billing.
  2. We will send you a link to complete your Practice Profile that will provide us with information to start building your website.
  3. After billing is set up, we will create your website within two weeks.
  4. You will verify the website content for accuracy.
  5. We will launch your website on the Web and list it in our doctor directory (if applicable).
  6. We will work with you to enhance and market your website after the launch date, according to your website goals.