Polished and Profitable Intake Form

SCHEDULING

*For either the last 12 months or last full calendar year.

Scheduling Owners/Doctors

Owners/Doctors	Clinical Hours Worked	Production	Total Collections	Actions

There are no Entries.

Scheduling Associate Dentists

Associate Dentists	Clinical Hours Worked	Production	Total Collections	Actions

There are no Entries.

Scheduling Hygienist

Hygienist	Clinical Hours Worked	Production	Total Collections	Actions

There are no Entries.

Scheduling Administrative

Administrative	Total Hours per Week	Actions

There are no Entries.

Scheduling Assistants

Assistants	Total Hours per Week	Actions

There are no Entries.

Scheduling Other Team Members

Other Team Members	Total Hours per Week	Actions

There are no Entries.

Calendar Hours Works Doctor

Doctor(s) (names):	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Actions

There are no Entries.

Calendar Hours Works Hygienist

Hygienist(s) (names):	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Actions

There are no Entries.

Is your schedule booked in 10 or 15 minute increments?

What practice management software do you use?

How soon could your office see a new adult patient who phones right now for an appointment?*

Do you double book and/or overbook patients?

Do you overlap patient appointment times?

How many weeks ahead are the dentists’ appointments scheduled?*

How many weeks ahead are the hygienists’ appointments scheduled?*

How many weeks off do you take each year?*

How many weeks off would you prefer each year?

How many days per week would you like to work?

How many non-patient hours do you work (“on” the practice) each week?