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Dr. Name: (required)

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Legal name of the practice:

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# of hygienists:

# of Assistants:

# of Front Office Staff:

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Type / Age Range of Patients/ Personality of the office?

Avg Weekly Doctor Production:

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Approximate age of equipment:

Right/Left Handed:

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First names of HygieniSTS:

First names of Assistants:

First name of Front Office:

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Avg Weekly office production:

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Do you accept Medicaid?

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What % is Medicaid if yes:

Check the associations you are a current member of:

State Dental AssociationADAAGD

Do you have any State Board or Liability issues pending with in the last 24 months?

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What percentage of weekly revenue is insurance

What is your Specialization? Please enter your name next to your specialization

Do you have multiple offices locations?

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Weekly Office Schedule: Hours Of Operation

Do you RX schedule C narcs?

What do you typically prescribe?

Do you utilize conscious or iv sedation?

What is the protocol for emergencies?

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Does the office have an adverse weather conditions plan?

Hotels that would be near the office:

Current Dental Supply company? Rep name?

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Are you an Equal Opportunity Employer?

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