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Consultation Form


Primary Information:

* Doctor's Name:
* Practice Name:
* Practice Address:
* City:
State:
Zip:
* Personal Email:
* Work Phone#:
* Cell Phone#:
* Fax#

1. Number of Ops:

* Total:
* Currently Equipped:
* Treatment:
* Hygiene:

2. Current location:

* Estimated number of Active Patients?
* How many years have you been there?

3. Additional Locations:
* Are there additional locations?
Yes
No
If yes, location address:

4. Number of Staff:
* Chairside:
* Admin:
* Staff:
* Hygiene:
* Associates:

5. Are there a partner/partners in the practice that make practice decisions?
* Answer:
Yes
No

6. Marketing:
* What are you currently doing?
* What are your new patient offers?
* What has not worked in the past?

7. What are your top concerns about your practice?
* a.
* b.
* c.
* d.


8. What are the biggest challenges in your practice?
* Answer Here


9. What is your ideal outcome?
* Answer Here

10. What Prior Management Consultants have you used and when:

* a.
b.
c.
If so, what results did you see with the previous consultants?

11. Over the Past 5 Months, What Has Been the Production of Your Practice?

Last Month:
* Practice Production:
* Practice Collections:
* # New Patients:

Month 2:

* Practice Production:
* Practice Collections:
* # New Patients:

Month 3:
* Practice Production:
* Practice Collections:
* # New Patients:

Month 4:
* Practice Production:
* Practice Collections:
* # New Patients:

Month 5:
* Practice Production:
* Practice Collections:
* # New Patients:

All Done! Click 'Submit' to Send Your Answers:

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