Innexus Optical Website Setup Form

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Sign-Up:

Please complete the following information to sign-up for an Innexus website. Upon completion of this online form, you will receive a confirmation email and your website will be placed into production.

Practice Name *

Website Contact (Full Name) *

Website Contact Email *

Practice Owner(s) *

Practice Doctor(s): If applicable, please put them in the order you wish them to appear on the website.

Address *

City *

State *

Zip *

Phone *

Fax *

Multiple Practice Locations? *

YesNo

If yes, please provide additional location addresses and phone numbers.

Time Zone *

EasternCentralMountainPacificOther

Do you have a Facebook page for your practice? *

YesNo

What are your office hours? *

2: DOMAIN INFORMATION AND EMAIL

Do you have an existing website? *

YesNo

2-A: IF YES... (If no, please skip to section 2-B)

What is the address? (ie: www.yourdomain.com)

PLEASE NOTE: Upon subscribing to Innexus, your website domain name will be transferred to our account.

While we manage your domain name, it will always remain owned by YOU. There are no fees involved if you wish to move the domain in the future. We will contact you for approval before any domain renewal is performed.

Do you have access to where your domain name is hosted? (ie: Godaddy, Network Solutions, Eyefinity, Etc.)

YesNoI do not know

Name of Domain Registrar (ie: Godaddy, Network Solutions, Eyefinity, Etc)

Account Number

Account Username

Account Password

2-B: IF NO...

Do you require a NEW domain name? (ie: www.yourdomain.com)

YesNo

If yes, do you have any preferences regarding a domain name? (Example: yourcompanyname.com)

If yes, we will contact you via phone to discuss available domain names, purchase length and pricing.

2-C: EMAIL SETUP

Domain-based email is included with your Innexus website subscription. This enables you to advertise your website each time you share your email address. (ie: info@yourdomain.com)

Do you have existing domain based email (name@yourdomain.com)? *

YesNo

Do you use Outlook for each domain-based email you currently have? *

YesNo

Would you like domain based email setup with your new website? *

YesNoUnsure

PLEASE NOTE: All email addresses will end with @yourdomain.com. Please type the prefix for 1-5 email addresses you would like created at the time of set-up. You may add additional email addresses in the future. (If more than five email addresses are required, please call us after completing this form to add the rest.)

Email Address 1

Email Address 2

Email Address 3

Email Address 4

Email Address 5

3: GOOGLE ANALYTICS

Google Analytics is a no cost service that Google offers to track statistical information on your website by embedding a hidden code individual to your website. Among many other things it can track how many hits your website receives in a specific day, month and or year.

Do you already have a Google Analytics Account? (Not a Gmail account) *

YesNoUnsure

If Yes, please complete the following with your existing Google Analytics account login information. (If No, please complete the following with the information you wish to have associated with Google Analytics.)

Email (Login for Google Analytics Account) *

First Name *

Last Name *

Password *

Birthdate (For password recovery) *

4: WEBSITE DESIGN PREFERENCES

Practice name as it should appear on the website *

Doctor(s) name as should appear on the website *

Practice tagline as it should appear (Or not applicable) *

Contact info as you would like it to appear on the website banner (Address, phone, fax?)

Do you have a logo for your practice?

YesNo

If YES, we will email you at the address provided to obtain an electronic version of your logo. .EPS, or .PNG file formats are preferred if available.

If NO, please type your preferred font, or no preference

Design skin preference for your new website (To preview all design skins open a new tab, go to demo.getinnexus.com and click on the skin selector button in the top left-hand corner. *

Look and feel of website or focus of care *

Your Innexus website includes all of these iFeature, please select which features you would like to start with.

iCardiNewsletteriCalendariFormiBlogiStoreFacebook IntegrationMobile PlatformAppointment RequestMembers Only Section

Specific customer design requests

5: ADDITIONAL QUESTIONS

Do you participate with a lab? *

Do you belong to a buying group? *

How did you hear about Innexus? *

6: BILLING INFORMATION

To view pricing information, please open another tab a type getinnexus.com/pricing

Billing Contact (Full Name) *

Billing Contact Email *

Billing Address *

City *

State *

Zip *

Which Innexus setup option are you going to participate with? *

Month-to-Month, No Agreement12 Month Subscription Agreement24 Month Subscription Agreement

Account/Card Type *

VisaMasterCardAmerican Express

Card Number *

Cardholder Name *

Expiration Date (MM/YY) *

CVV2 (Three digit number on back of Visa/MC, four digit number on front of AMEX) *

Innexus Service Agreement

The most current copy of the Innexus service agreement may be found and reviewed by visiting http://www.getinnexus.com/agreement. I understand this service may be cancelled at any time, with no cancellation fees by providing a 30-day written notice.

I have read and fully agree to the terms and conditions outlined in the Innexus Service Agreement. *

Yes

Electronic Signature: please provide an electronic signature by typing your name in the box below. *

Enter the verification code in the box below.

Verification Code: *

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