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Type of practice (GP, Endodontic, Orthodontic, Oral Surgery, Prosthodontic)
Number of years in practice
Number of restorative treatment rooms
Number of hygiene treatment rooms
Average number of doctor days worked each week
Average number of hygiene days worked each week
Production for the last twelve months (or specified period)
Collections for the last twelve months (or specified period)
Number of new patients for the last twelve months (or specified period)
Number of openings in the doctor schedule for the next three weeks
Number of openings in the hygiene schedule for the next three weeks
What are the top one to three areas of biggest concern?
Dentist Name
Practice Name
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Telephone - ### - ### ####
Fax - ### - ### ####
Web URL