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Polished and Profitable Intake Form
INTAKE FORM
Coaching with Jennifer LaRocca
Step
1
of
4
25%
OFFICE INFORMATION
Practice Name
*
Practice Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Other Locations
Phone Office
*
Phone Cell
Email
*
Total Number of Operatories
*
How Many Are Hygiene
*
How Many Are Restorative
*
How Many Are Specialized
*
How Many Are Plumbed
*
How Many Are Equipped
*
SCHEDULING
*For either the last 12 months or last full calendar year.
Scheduling Owners/Doctors
Owners/Doctors
Clinical Hours Worked
Production
Total Collections
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Scheduling Associate Dentists
Associate Dentists
Clinical Hours Worked
Production
Total Collections
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Scheduling Hygienist
Hygienist
Clinical Hours Worked
Production
Total Collections
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Scheduling Administrative
Administrative
Total Hours per Week
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Scheduling Assistants
Assistants
Total Hours per Week
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Scheduling Other Team Members
Other Team Members
Total Hours per Week
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Calendar Hours Works Doctor
Doctor(s) (names):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Calendar Hours Works Hygienist
Hygienist(s) (names):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Is your schedule booked in 10 or 15 minute increments?
10 Mins
15 Mins
Other
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?
Yes
No
Do you overlap patient appointment times?
Yes
No
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?
MARKETING
How much competition do you feel from other practices in your area?
Little to none
Medium
High
Do you have a marketing plan?
Yes
No
Please name three goals of your plan
How successful is your marketing plan, based on a scale of 1-10? (10 being the most successful)
Do you or your team ask your regular patients to invite family or friends to your practice?
Doctor
Team
Both
What methods do you currently use to measure your practice’s effectiveness for the following systems?
Case Acceptance
Patient Retention
Schedule Utilization
Team Performance
FINANCIAL
Please allocate insurance dependence in your practice (percent of each category):
PPO (%)
HMO (%)
Medicaid (%)
No Insurance (%)
3rd Party/Non-participating (%)
We are a fee for service practice. We do not accept insurance payments
What would you describe as your greatest challenge as a practice/team leader?
What areas of team performance, patient care and patient value/profitability would you like to improve in your practice?
Describe your goals (both personal & professional) for the next 5 years
Is there anything else you’d like us to know about your vision & goals?
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