New Client Survey

Business Name*
A valid business name. Example: XYZ Physical Medicine Center
Alternative Names
Has your business changed names, or been listed in sites like Yelp, Google Places, Yahoo etc. under a different name? If so, please list them here.
Address*
Street Address Address Line 2 City State ZIP Code
Do you need to add an additional location?
- Yes
- No
Location 2
Street Address Address Line 2 City State ZIP Code
Location 2 Phone
Do you need to add an additional location?
- Yes
- No
Location 3
Street Address Address Line 2 City State ZIP Code
Location 3 Phone
Has your business moved locations or phone numbers in the past 5 years?
- Yes
- No
Previous Address
Street Address Address Line 2 City State ZIP Code
Previous Phone Numbers

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Primary Contact Name*
First Last
Primary Contact Title*
Billing Contact Name
First Last
Main Phone*
Your main business phone number where you would like calls routed.
Alternate Phone
Mobile Phone
Fax
Email*
What email address would you like leads from LocalGiant sent to?*
Have you already registered a domain name for your business?*
- Yes
- No
Website/Domain
If you already have a website, put the URL to your site here. If you have multiple domains, you will be able to add those later on in the survey. Please just enter your primary domain name here. Example: http://www.yoursite.com
Previous Website Addresses
If you've had other websites in the past, what URLs have you used?
Number of Employees*
Please enter a number from 1 to 2000.
Year Established*

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Business Details
For the following questions, please add one response per line. You can use the icon below to add additional lines if necessary.
Team Members*
Please list your team and the best email address to reach them for their bio.
Name Title Email Address
Brands
Example: Standard Process, Invisalign, Zoom, etc.
Areas Served*
Example: Fort Collins, Loveland, Windsor
Credentials or Certifications
Example: Doctor of Osteopathy, Doctor of Chiropractic, Physicians Assistant, Licensed Personal Trainer, Licensed Massage Therapist, Medical Assistant, Chiropractic Assistant
Professional Associations
Example: Regional Chiropractic Association. National Society of Clinical Rehab Specialists, etc.
Services
Example: Physical Medicine, Chiropractic, massage, nutrition, weight loss, rehabilitation, lab testing, diagnostics
Professional Licenses
Please enter any licenses required to operate your business.
Description License Date Issued Date Expires
Email Accounts
Please list the email accounts and passwords you would like with your domain. You only need to enter the first name You may add up to 8 accounts.
Email Account: Desired Password

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Short Business Description*
Describe your business in 200 characters or less. Example: The finest italian restaurant in the area.
Long Business Description*
Unique Selling Proposition*
What set's your business apart? Why would a prospective customer choose your business over your competition? Please enter anything here you feel would help us promote your business.
Additional Information
Please enter anything here you feel would help us promote your business.
Favorite Websites*
Please list a few websites you like the look and feel of. This will help direct our design team to make sure your new site is one you love!
Phone
This field is for validation purposes and should be left unchanged.

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Account Name	Login URL	User Name	Password

Domain Name	Registered With	User Name	Password

Account Name	Login URL	User Name	Password

Business Details

Name	Title	Email Address

Description	License	Date Issued	Date Expires

Email Account:	Desired Password