You are invited to complete and submit the practice evaluation form below.

This courtesy evaluation includes analysis of practice information provided and a one hour call to 1 – discuss analysis results, 2 – identify areas of concern, and 3 – next steps to achieve practice goals. Once you submit your evaluation, you will be contacted to schedule a call. Have questions? Don’t hesitate to call or email us. We love to talk dentistry!

 

Dental Practice Evaluation

Please submit completed form online or fax PDF version to 727-674-1985.
All fields are optional. If you do not have all of the information available to complete the form, please estimate or leave blank.

For a downloadable PDF version, click here.

    Best phone number to contact you to review your practice evaluation:

    Name (required):

    Practice Name:

    Address:

    Email Address: (required)

    Office Phone Number:

    Number of Dentists in practice:

    General: Specialist:

    If specialist(s), please enter type of specialist(s):

    Years in Practice:

    Total Gross Production Last Year:

    Total Net Production Last Year (after adjustments):

    Monthly Production Goal:

    Total Collections Last Year:

    Monthly Collection Goal:

    Total Hygiene Production Last Year:

    Monthly Hygiene Goal:

    Number of Hygiene Days per Month:

    Total Accounts Receivable:

    Number of Team Members:

    Hygienists:

    Assistants:

    Administrative:

    Other:

    Number of Active Patients:

    Average Number of New Patients Monthly:

    Annual Marketing Budget:

    Average of Fee of Cases Presented:

    Average Percentage of Case Acceptance:

    Percentage of Patients with Dental Insurance:

    PPO:

    HMO:

    Medicaid:

    Number of Insurance Plans Accepted:

    Areas of concern: