The Website Surgeon - Patient Intake Questionnaire

Please help us mutually determine if our expertise and your needs are an ideal fit. Your time is valuable; the more information we have on what you are looking for, the more valuable our conversations will be.

Once your intake form is submitted successfully, you will be directed to the confirmation page. Please allow us up to two (2) business days for us to review your submission and provide a detailed response.

Your Contact Information
Your Name:*
Company Name:
Your E-Mail Address:*
Telephone Number:*
Preferred Contact Method:
Best Time to Contact: (please note your time zone)
How did you hear about The Website Surgeon?
If you were directly referred to us, please name the referring person/organization:
Your Current Internet Presence
Do you currently have active websites? If so, how many?
Please list the URL(s) of your sites:
What compan(ies) do you currently use for website hosting? (check all that apply)		AACES
		CrystalTech
		DreamHost
		GoDaddy
		HostGator
		Hostway
		InfoQuest
		iPowerWeb
		Network Solutions
		1and1
		RackSpace
		WestHost
		Yahoo!
		Other

What compan(ies) do you use to register your domains? (check all that apply)		DirectNIC
		eNom
		GoDaddy
		Hostway
		InfoQuest
		Network Solutions
		1and1
		Tucows
		WestHost
		Other

Do you currently have active Weblogs?
If "yes," what technologies power them? (check all that apply)		Blogger
		Movable Type
		Typepad
		WordPress
		Other
Your Current Internet Technology
	Shopping Cart System?
	Opt-In Autoresponder System?
	Periodic Ezine?
	Affiliate Management System?
	Survey Mechanism?
	Web Audio Publisher?
	Website Statistics Tracking?
	Other?	AdImpact
		Flash Video (FLV)
		InstantTeleseminar
		Instant Video Generator
		Podference
What We Can Do For You
Please describe, in as much detail as possible, what project(s) and/or solution(s) you are looking for us to provide:


What is your most pressing need - what would you like our help with first?


What is your timeframe for completing the first project (please be more specific than "ASAP" - what deadlines are in place, what campaigns or initiatives are dependent upon project completion, etc.)?


Which of the following additional solution(s) would you be interested in, if any?		Custom WordPress Weblog Application
		HTML Ezine
		Recommends Site
		Virtual E-Course Setup
		Article Submission
		Squeeze Pages
		Sales Letter Minisite
Organizational Information
What is your monthly budget for internet marketing efforts?
Who has provided your webmaster solution thus far?
Does your organization have a Virtual Team?

Would you be comfortable working with a firm of highly-trained professionals where several people, each possessing unique skills and talents, will work together to deliver your top-notch solution, under the guidance and supervision of an expert Virtual Webmaster?


Additional Comments or Questions:

We are fanatically dedicated to maintaining your privacy.
Please know that we will never share, rent, lease, or sell your information
to anyone, for any reason. Ever.