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OnTheGo

Please take a few minutes to tell me about your practice. Thank you.

 
Name:
Practice Name:
Address 1:
Address 2:
Tel:
Email:
Are you a Specialist?
 Yes  No
If yes, what Specialty?
Do you employ a Specialist?
 Yes
 No
If yes, what Specialty?
What are your annual collections?
 Under 450K
 451-575K
 576-725K
 726-850K
 851-1M
 Over 1M
How many hours per week does the doctor and associates work?
 
Doctor 1:
Doctor 2:
Doctor 3:
Doctor 4:
Associate 1:
Associate 2:
Associate 3:
Associate 4:
How many total hours do your non-doctor employees work per week? Please inlclude full and part-time
How many active* patients do you have in your practice? *Active is defined as the number of patients seen in your preventive care dept in the last 18 mos.
 Uner 400
 400-800
 800-1200
 1200-1600
 1600-2000
 2000-2500
 More than 2500
If under 800, how many?
When was your last fee increase?
What is your practice's overhead percentage?
 Over 75%
 65-75%
 60-65%
 Under 60%
What is your current Accounts Receivable?
 More than 3x last month's production
 2-3x last month's production
 1-2x last month's production
 Less than 1 month's production
What % of your practice's overall production do you collect?
 Below 80%
 80-90%
 90-95%
 Over 95%
What does your hygiene department produce per hygienist?
 Less than 2x their daily salary
 2-3x their daily salary
 3-4x their daily salary
 More than 4x their daily salary
How many hygiene patients change their appointment (ie cancellations/no shows) per week?
 More than 7
 5-7
 3-4
 Less than 3
How does your practice diagnose and treat periodontal disease?
 We only see 6-month recalls
 PSR screening
 PSR screening, vertical bitewings, some 3-4 month recalls
 Full mouth, 6-pt probing, FMX, vertical BW updates, standard treatment perio program
Of your last 10 case presentations, how many patients scheduled an appointment to continue treatment?
 None  1-2 patients
 3-5 patients  6-10 patients
Are you satisfied with your monthly patient flow?
 Never
 Seldom
 Sometimes
 Always
 Have stopped taking NPs
 
What is your average number of patients per month?
How often do you hold staff meetings?
 Weekly
 Monthly
 When there is an issue to discuss
What is the stress level in your practice?
 Our practice is out of control
 Our practice is constantly in a state of conflict
 We feel like there's never enough time in the day
 We enjoy coming to work
If other, please describe briefly:
If there was one problem or issue you could resolve immediately, what would it be?
 Production
 Collection
 Staff issues
 Patient issues (cancellations, no-shows)
 Payment arrangements
 Other
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