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Name

Practice Name

Address

Email Address

Office Phone Number

Number of Dentists in Practice - General

Number of Dentists in Practice - Specialist

If Specialist(s) please enter type of Specialist(s)

Year in Practice

Total Gross Production Last Year

Total Net Production Last Year

Monthly Production Goal

Total Collections Last Year

Monthly Collections Goal

Total Hygiene Production Last Year

Monthly Hygiene Goal

Number of Hygiene Days per Month

Total Accounts Receivable

Number of Team Members

Number of Hygienists

Number of Assistants

Number of Administrative

Number of Other

Number of Active Patients

Average Number of New Patients Monthly

Annual Marketing Budget

Average of Fee Cases Presented

Average Percentage of Case Acceptance

Percentage of Patients with Dental Insurance PPO

Percentage of Patients with Dental Insurance HMO

Percentage of Patients with Dental Insurance Medicaid

Number of Insurance Plans Accepted

Areas of concern