How many years have you been practicing?

0 - 5 years 6 - 10 years 11 - 20 years 21 - 30 years 30+ years

Do you think about the practice while at home?

Yes No Sometimes

What percentage of the day are you spending on administrative tasks versus dentistry?

0 - 10% 10 - 20% 20 - 30% 30 - 40% 40 - 50% 50 - 60% 60 - 70% 70 - 80% 80 - 90% 90 - 100%

Do you pay yourself a regular salary or draw?

Regular Salary Draw

Do you have multiple locations?

Yes No

Are you thinking about expanding?

Yes No

When is the best time to contact you? (Ctrl + Click to select multiple days or times)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning (8:00 - 12:00) Afternoon (12:00 - 4:00) Evening (4:00 - 8:00)

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How many team members do you have?

Do you have an office manager?

Yes No

Do you have a treatment facilitator?

Yes No

How many dentists work in the practice?

How many hours per week are your dentists available?

Do you utilize restorative hygiene?

Yes No

How many hygienists work in the practice?

How many hours per week are your hygienists available?

Do you utilize a CDA II to assist hygiene?

Yes No

Do you have any dental specialists in the office?

Yes No

If yes, what type of specialists are they?

If yes, what is their frequency in the practice?

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How many operatories do you dedicate to dentists?

How many operatories do you dedicate to hygienists?

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Approximately how many active patients does the practice have? (Active patient equates to at least one visit in the last 24 months)

How many new patients does your practice gain each month?

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Are your operatories computerized?

Yes No

Do you have a server on-site at the practice?

Yes No

What scheduling software do you use?

Dentrix Abeldent Tracker Other (please specify)

Do you use software to automate reporting?

Yes No

Do you use software/email to communicate with your patients? (e.g. appointment reminders, upcoming promotions, etc.)

Yes No

Do you use videos, clinical imaging, or diagnostic software to enhance case acceptance?

Yes No

Do you have a website?

Yes No

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On a scale of 1 to 10 (1=lowest, 10=highest), how would you rate the following?

Area	Rating
Overall Clinic :	1 2 3 4 5 6 7 8 9 10
Performance of your team :	1 2 3 4 5 6 7 8 9 10
Practice patient growth:	1 2 3 4 5 6 7 8 9 10
Production / Collections:	1 2 3 4 5 6 7 8 9 10
Your facility and equipment:	1 2 3 4 5 6 7 8 9 10

Please check the 3 biggest challenges that impact your practice.

Team IssuesOrganization & ConsistencyStress & ChaosPatient CommunicationLack of New PatientsFinancial plateau or decline in the past 2 yearsCollections & Accounts ReceivableClient Financial ConcernsNo Shows & CancellationsClient Case AcceptanceProfit & Cash FlowHygiene Department

Team IssuesOrganization & ConsistencyStress & ChaosPatient CommunicationLack of New PatientsFinancial plateau or decline in the past 2 yearsCollections & Accounts ReceivableClient Financial ConcernsNo Shows & CancellationsClient Case AcceptanceProfit & Cash FlowHygiene Department

Team IssuesOrganization & ConsistencyStress & ChaosPatient CommunicationLack of New PatientsFinancial plateau or decline in the past 2 yearsCollections & Accounts ReceivableClient Financial ConcernsNo Shows & CancellationsClient Case AcceptanceProfit & Cash FlowHygiene Department

In your ideal practice, what 3 things would be different?

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• Submit

Section	# Of Errors	Errors	Status
General Information	7		Incomplete
About You	7		Incomplete
About Your Team	7		Incomplete
Practice Details	7		Incomplete
Practice Growth	7		Incomplete
Information Technology	7		Incomplete
Final Thoughts	7		Incomplete

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