Pre-Installation Form (New Clients)

General Information

Please fill out the following information as best you can

What Practice is this for?

Preferred Install Date

Number and Person to contact for the Installation (Requires Admin Server Credentials)

List the names of the Providers who will have an online scheduling profile with LocalMed:

How would you like returning patients to view recall openings:

How long do you schedule New Patient Cleanings for adults?

How long do you schedule New Patient Cleanings for children?

How long do you schedule Returning Patient Cleanings for children?

How long do you schedule Returning Patient Cleanings for adults?

How long do you schedule New Patient Emergency/ToothPain?

How long do you schedule Returning Patient Emergency/ToothPain?

How long do you schedule New Patient Consultation? (Copy)

What is the name of the person or company who created and manages your website?

Are you in Network with United concordia?

Do you offer Six Month Smiles or Invisalign as an option to your patients?

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