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PRACTICE DATA

First Name

Last Name

Phone

What year did you graduate from your endodontic residency?

How many years have you owned your practice?

How many hours are available for scheduling patient appointments in a typical full work day?

How many days per week do you work in a typical full work week?

How many vacation weeks do you take each year?

For a typical full work day, on average how many cases do you complete each day?

What was your total production for last year?

What were your total collections for last year?

Molar root canal fee?

How many years since you last raised your fees?

Roughly estimate the number of A referrers (sends 12 or more cases per year)

Roughly estimate the number of B referrers (sends 5 to 11 cases per year)

Roughly estimate the number of C referrers (sends 1 to 4 cases per year)

Share any other objectives, concerns or factors that will help us better understand your practice and goals.