Name:     Email:

Address:     

City:    State:    Zip:

Phone:

Name of Practice:

Contact Person:
E-mail Address:
Phone:

CURRENT WEB PRESENCE
Do you currently have a website?  Yes        No
Do you need your store to serve as a website by having practice information included? Yes        No
If you have a website, what is your Website URL:

Who is your webmaster:

And host:

How many offices do you currently have?
What is your average monthly gross revenue from product sales per office?
What is the general demographic of your patient population? (age, sex, race, bilingual)
What is the general socio-economic category of your patient population?
Are you in a predominantly rural, suburban, or urban location?
 

Have you ever had an eCommerce Store?      Yes       No
What about your store, did you like best?
What were the problems you experienced?
What changes would have made it a better experience for you or your patients? 
 

YOUR NEW STORE PREFERENCES
Would you prefer to have a store whose custom header is identifiably “Your Online Store” or a banner to link to an anonymous generic store providing the same revenue share?

Do you want your store to reflect the colors, theme, logos, pictures and appearance, as similar or different from your current website?     Yes         No

What are your most frequently suggested or recommended products?

What additional products would you like to make available?

What are the most frequent co-morbidities you see in your patient population?


What percentage of your patients shop online?

Please mark promotional items you think you might need to promote your new store:

Posters
Coupons
Brochures
Handouts
Discount Cards
Step by Step Directions (for ordering on your e-store from their computer or your computer),
Script Pads (containing suggestions of products)
Pre-Registration Assessment Sheet (to determine the patient’s use of Nutriceuticals,
     Skin Care products, Medical Supplies, and needs of Aids for Daily Living),
Appointment Cards (as reminders of Your eStore).
E-mails (with health information or reminders of your product recommendations)

Are you interested in expanding the scope of your practice to include addressing comorbidities or programs of health, wellness and anti-aging?     Yes      No
Would you be interested in Product Education via monthly podcast to equip your staff in understanding the value and use of different products for your patients?  Yes      No
Are you happy with the design of your current website?  Yes      No
Are you considering a website “makeover”?   Yes      No
Are you interested in new patient portals to reduce your staff’s distractions and phone time? Yes      No

Mark those in which you may be interested:
Pre-Registration Online Appointment Request Patient Pay Online
Prescription Request “Ask Your Doctor”
Private forum “Doctors Blog” to discuss issues with other Physicians, Podiatrists or Compounding Pharmacist?
GPO (group purchasing organization) to order products, equipment, furnishings, and medical supplies?
Personal needs in the GPO, like travel packages, insurance, auto maintenance, etc. exclusively for physicians.
Video introduction of your practice for your website?
Procedure animations or your patient’s education, post op care, or product use?
Having your appointment availability broadcast on the internet?
Daily health news on your website?
Monthly newsletter or a “foot health” educational flyer available for your website?
Emails as reminders for patients to acquire recommended products?
Using email, for promotions or as reminders of practice programs, product sales and specials?
A Facebook Storefront or Mobile Commerce with your storefront being accessible via mobile phones?

How did you hear about MyDocDirect.com?

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