Request for Information

REQUEST FOR INFORMATION

27 Point Dental Practice Systems Assessment

Our in-depth Practice Systems Assessment gives us the data we need to accurately pinpoint areas of your practice that are performing well and those areas that need improvement. Once all the data is gathered, we spend a great deal of time studying and assessing the information so that we can accurately report back to you and make recommendations. We gather data from the last two years so as to spot trends and obtain good averages.

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Request For Information Form

Section 1 - Office Totals:

RFI Year(Required)

Today's Date

Practice Name(Required)

Office Production ($)

Collections ($)

Month End Accounts Receivables ($)

Front Desk Collections ($)

Total Number of Recall Exams (Code: 120)

Active Patient Count (Last 18 Months)

Total Number of New Patients (Code:150)

Total Soft Tissue (Perio) (Code: 4910, 4341, 4342)

Total Number of Prophies (Codes: 1110, 1120)

Section 2 - Doctor Totals:

Doctor's Name

First Last

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (Do Not Include Hygiene Checks)

Write-offs (Insurance + Discounts)

Total Crown & Bridge Production

(Codes: 6010, 6199, 2740, 2920, 2954, 6245, 6548, 6999)

Add Additional Doctors

Doctor's Name

First Last

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (Do Not Include Hygiene Checks)

Write-offs (Insurance + Discounts)

Total Crown & Bridge Production

(Codes: 6010, 6199, 2740, 2920, 2954, 6245, 6548, 6999)

Doctor's Name

First Last

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (Do Not Include Hygiene Checks)

Write-offs (Insurance + Discounts)

Total Crown & Bridge Production

(Codes: 6010, 6199, 2740, 2920, 2954, 6245, 6548, 6999)

Doctor's Name

First Last

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (Do Not Include Hygiene Checks)

Write-offs (Insurance + Discounts)

Total Crown & Bridge Production

(Codes: 6010, 6199, 2740, 2920, 2954, 6245, 6548, 6999)

Doctor's Name

First Last

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (Do Not Include Hygiene Checks)

Write-offs (Insurance + Discounts)

Total Crown & Bridge Production

(Codes: 6010, 6199, 2740, 2920, 2954, 6245, 6548, 6999)

Section 3 - Hygiene Information

Production ($)

Hours Worked (Actual Time Spent With Patients)

Patient Visits (#)

P & L From Accountant

Max. file size: 50 MB.

Provide Two Full Years

2022 Fee Schedule

Max. file size: 50 MB.

File

Max. file size: 50 MB.

Hourly pay for each staff member + days of the week everyone works and the hours they work each day

Pay Hours and Staff Report

Max. file size: 50 MB.

What dental software do you use?

(i.e. Softdent, Eaglesoft, Dentrix):

Please share comments and concerns about your practice.

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