Clinic Information

Clinic Name:

Primary Contact Name:

Contact Email:

Contact Phone Number:

Clinic Website URL:

Number of Clinic Sites/Locations:

Number of Staff Members:

Services and Specialties

Therapy Services Offered (select at least one):

Physical Therapy Occupational Therapy Speech-Language Therapy Other

Patient Populations Served (select at least one):

Average Monthly Patient Volume:

Patient Communication Preferences

Preferred Languages for Patient Communication:

Chatbot Deployment Channels

Select the platforms where the chatbot will be available for patient interactions (select at least one):

Chatbot Customization Needs

Briefly Describe Your Clinic’s Protocols and Policies:

Branding Preferences (e.g., tone, logo, colors):

Primary Goals for Chatbot Implementation:

Technical and Compliance Requirements

Website Platform:

Does your chatbot need to comply with HIPAA for handling Protected Health Information (PHI)?

Yes, it will handle PHI and requires HIPAA compliance No, it will only provide general clinic information (e.g., hours, services) and does not need HIPAA compliance

Existing Systems for Integration:

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