Contact Information
Date:
Doctor's Name:
Practice Name:
Associates:
Partners:
Address:
City, State, Zip
Backline Number:
Home/Mobile Number :
Fax Number:
Cell Number:
E-mail:
General Practice Information
How many years have you been in practice?
Are you a solo practice or partnership?
Is this the only practice you own?   Yes   No
(More than 1 doctor) How many days a week does each doctor work?
Doctor 1:
Doctor 2:
Doctor 3:
Doctor 4:

(More than 1 doctor) Do you share hygienists?
Number of employees within the practice (including doctors):
On a scale of 1-10, how would you presently rate your practice overall?
If you did not rate the practice as a 10, explain why not or what it would take to make it a 10.
On a scale of 1-10 how would you rate your team?
If you did not rate it as a 10, explain why or what it would take to make it a 10.
On a scale of 1-10 how would you rate your overall leadership and management skills?
If you did not rate them as a 10, explain why not or what it would take to make them a 10.
Please check all the areas you would like assistance:
Vision  
Practice Management Systems & Organization
The New Patient Experience
Scheduling for Production/Collections
Case Presentation & Closure
Financial Arrangements
Team Co-diagnosis, Communication and Verbal Skills
Hygiene Comprehensive Care: Aesthetics enrollment, non-surgical periodontal treatment, understanding of functional reasons for aesthetic dentistry, occlusion & understanding the business of dentistry.
Patient Retention and Recare
Team Building - Conflict resolution, team & patient communication
Customer Service  
Have you ever worked with a consultant in the past/present? Yes No
If yes, Name:
When:
How many new patients are you attracting per month?
Rate the current economic status of your area (check one):
High Moderate-High Moderate Moderate-Low Low
Facility Space Evaluation
Total number of treatment rooms:
How many are devoted to hygiene?
How many not in use?
Discuss any future plans to expand:
Scheduling
How far in advance are you scheduled solid in Hygiene?
How far in advance are you scheduled solid in Restorative?
How far in advance are you scheduled in Hygiene?
How far in advance are you scheduled in Restorative?
Are you experiencing openings and frequent changes in the schedule?
How many patients does each Hygienist see per day?
List how much time your Hygienists spend with each patient during the following:
Prophy:
Root Plane:
Pedo Prophy:
Perio Prophy (Supportive Periodontal Therapy:
Are your Hygienists constantly running behind?
Do you pre-block the schedule for production? Doctors   Hygiene
In regard to scheduling, what is your daily ($) Goal: Doctors: Hygiene:
Hygiene Department
How many hygienists to you have working full-time?
How many Hygienists do you have working part-time?
How many hours of Hygiene do you currently have per Hygienist?
Monday:
Tuesday: 
Wednesday:
Thursday:
Friday:
Saturday:
Do you credit Hygiene with exams, fluoride, electric toothbrushes, X-rays etc? Yes No
Do you track cancellations? Yes No
How many cancellations do you average per day?
List the percentage (%) of patient on Recall on a:
12-month basis:
6-month basis:
4-month basis:
3-month basis:
2-month basis:
1-month basis:
Financials
Do you have PPO's, Capitation, or Discount plans (UK - Den Plan, NHS?
What percentage (%) of your practice is the above?
Do you plan to keep them:
Amount of Accounts Receivable
Please list the fees for the following:
01110 Scale & Polish:
04910 Perio Maintenance:
04341 Root Planing:
Porcelain to metal crowns to
All porcelain crowns to
Veneers to
Direct Composites to
Inlays / Onlays to
Are you satisfied with what you are charging? Yes No
Hygienists daily average: $ UK£
$ UK£
$ UK£
Doctor's daily average:  $ UK£
$ UK£
$ UK£
Total Gross Turnover for the past 12 months in (dollars or pounds for UK)?
Do you know your monthly B.A.M. (Basic Amount of Money for practice to break-even per Month?
Total number of days worked last year?
Total number of hygiene days last year?
List any major transitions you are currently going through (i.e., hiring, firing, ownership, association, partnership, moving or remodeling): 
Please use the box below to discuss your specific personal goals for the practice:
Please fax us a production report for the past 12 months that includes:
1. All Providers
2. Numbers of procedures by ADA Codes
3. Total Production for the Period
This information can be faxed to (949) 297-3822
Please list your specific contact information. You will be contacted to set up a telephone appointment to discuss this analysis. - Thank you!
Contact Person:
Contact Telephone:

Please click "submit" and your analysis form will be sent directly to our office.