Project Intake Form Stakeholders Project Manager (Name) IT Point of Contact (Name) IT Point of Contact (Email) Business Contact Business / Practice Name Contact Name Contact Email Contact Phone Project Type Project Type Select…New constructionAdditional locationTakeoverMoveMSPOther Target Opening Date Configuration Date (Auto: 7 days prior) Automatically calculated when Target Opening Date is selected. VPN Required? Yes No Static IP Available? Yes No Date to Acquire Static IP WAN Details LAN Details Equipment Equipment Needed Pan (2D/3D) Sensor IO Camera Checking an item will reveal the required details. Pan Type Select…2D3D Pan Make Pan Model Pan Serial Interface Select…USBEthernetProprietaryOther Interface (Other) Sensor Quantity (1–10) Enter quantity to generate make/model/serial rows. IO Camera Quantity (1–10) Enter quantity to generate make/model/serial rows. Software – Practice Management Practice Management Select…CloudOpen DentalDentrixEaglesoftOther Cloud URL Open Dental – Encryption Phrase Open Dental – Server Dentrix – Encryption Phrase Dentrix – Server Eaglesoft – Server Imaging Software Imaging Software Title Quantity (Seats) Infrastructure Switch(es) Firewall Modem Credentials Static IP Information LAN Subnet Information DHCP Server Remote Access Existing Need Number of Remote Users VoIP VoIP Provider Extension Count Peripherals Printers (Count 0–10) Rows will appear based on count. Scanners (Count 0–10) Rows will appear based on count. Submit Reset Note: This HTML submits to /submit-project-intake. Add a backend to email/save.
