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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:

Practice Name:

Address:


Email Address:

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:

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