New Client Form

Fill Out the Form to Request an Appointment

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Doctor/practice Name(Required)

Birth Date(Required)

Mailing Address(Required)

Office Phone Number(Required)

Doctor’s Cell Number(Required)

Email Address(Required)

Brief History of Career of Dr. And/or Practice(Required)

Year Graduated From Dental School(Required)

How Long Have You Been in This Facility?(Required)

Your Practice Vision(Required)

How Did You Reach the Decision That You Wanted a Dental Consultant?(Required)

Your Expectations and Goals of Definitive Dental Solutions Consultants(Required)

What Is the Practice Management Software? Is It the Most Recent Version? Is There a Standard Protocol for Backup in Place?(Required)

Is Chair-side Computers Used Effectively?(Required)

Is the Entire Team Cross-trained in the Effective Use of the Software for Making Appointments, Posting Payments, Printing Insurance Forms, and Generating Necessary Reports?(Required)

How Many Chairs?(Required)

Doctor Chairs?(Required)

Hygiene Chairs?(Required)

Consult Room?(Required)

Do You Feel the Practice Is Patient Saturated and Needs an Associate; Does the Facility Have the Chair Space to Make This a Possibility?(Required)

What Are the Opportunities for Expansion in the Facility, if Any?(Required)

Please List Your Provider Team’s Hours:

Dr's Name/Schedule/Total hours

Doctor and Hygiene Provider Productivity Report: (Total Amount Produced Per Provider in the Last Twelve Months)*

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Total Gross Production(Required)

Total Production Adjustments(Required)

Total Net Production(Required)

Total Collected(Required)

Doctor Provider Schedule: Access to 2 Chairs Yet Scheduled Mostly in One Chair?(Required)

Is the doctor(s) always scheduled in 2 chairs each day?(Required)

Does the appointment book reflect the doctors and assistant’s time utilization?(Required)

Does the team follow any scheduling template for ideal doctor(s) schedule patterns?(Required)

Please calculate in the last four weeks: Total units of open doctor(s) time(Required)

Is open time for the doctor(s) negligible, minimal, or significant? Does open time in the doctor’s schedule occur because it was never scheduled, or because of same day schedule changes?(Required)

What resource does the team use to recover open doctor time?(Required)

Associates in the practice(Required)

Has the senior doctor determined which patients will be allocated to the associate(s)?(Required)

When the associate(s) joined the practice, was a new assistant assigned to support the associate?(Required)

Does the associate(s) perform recare exams for an established patient base?(Required)

Hygiene Active Patient Base: (Should you have any problems pulling the reports required for information, I will happily walk you through the process) # Total pre-scheduled for hygiene today into the future 12 months

# Future due and unscheduled today into the future 12 months

# Overdue and unscheduled hygiene patients 0-6 month

Hygiene allocation – does each hygienist have her/his own patient base?

Document the number of procedures performed in the below individual hygiene procedure codes for the last twelve months:

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How long is a typical preventative appointment?(Required)

What is the scheduled increment, 10 or 15 minutes?(Required)

Describe the steps the practice uses to contact scheduled, unscheduled and overdue patients in the practice. For example, how are scheduled hygiene patients contacted to ensure they are keeping their appointments?(Required)

If you mail recare cards, and or If you contact your patients via e-mail or text for recare appointments what is the time frame before the appointment?(Required)

Is there an assigned person whose job it is to look after the recare process in the practice?(Required)

How does the practice deal with patients who cancel or delay recare visits?(Required)

How many people oversee or manage the hygiene schedule?(Required)

What is the usual approach to inactivating a patient? Who does it, and based on what criteria?(Required)

Please calculate in the last four weeks: Hygiene hours available? Hygiene hours open?(Required)

Is open time in the future hygiene schedules negligible, minimal, or significant?(Required)

Where are most of the hygiene appointments scheduled, chair-side or at the dismissal desk?(Required)

What resource does the team uses to recover open hygiene time?(Required)

Are your computer-generated treatment plans accurate?(Required)

How does the team follow up on patients who delay, decline or cancel doctor appointments?(Required)

How many new patients have you seen each month over the last 6 months?(Required)

How long is the new patient’s first appointment scheduled for?(Required)

Briefly describe your new patient examination process and documentation. Is the new patient scheduled to see the doctor or hygienist first?(Required)

Are existing conditions noted?(Required)

Are treatment plans phased or put in appointment priority in the computer and or chart?(Required)

Are patients presented with a verbal or pre-printed treatment plan at the conclusion of their first visit?(Required)

What documentation is presented to the patients that need comprehensive dentistry and what do they take home?(Required)

Are financial options available to help patients finance their dental needs?(Required)

Does the practice have a documented financial policy? Please attach a copy

Max. file size: 100 MB.

Does the practice have a documented financial policy? Please attach a copy

Does the practice calculate the patient portion for each visit, and do patients usually pay that amount?(Required)

How are overdue accounts handled?(Required)

Accounts Aging: 0-30 days(Required)

Accounts Aging: 31 – 60 days(Required)

Accounts Aging: 61- 90 plus days(Required)

Does the practice charge interest on overdue accounts? Is there a cancellation penalty, and does the practice have success in collecting that amount?(Required)

Who creates and sends statements? How often are statements sent out?(Required)

Does the team have complete confidence in applying insurance payments correctly? What fee schedule does the practice follow – insurance or practice UCR?(Required)

Do patients pre-pay for large cases causing credit balances?(Required)

How much do you currently have in patient account credits?(Required)

Does the team meet for huddles? How long are the huddles?(Required)

How does the team feel about the huddles, do they provide focus, education, and opportunities to discuss patient concerns or scheduling issues?(Required)

Do you have team meetings?(Required)

Are formal job descriptions in place? Are performance evaluations held regularly?(Required)

How are new patients tracked and how do you acknowledge referrals?(Required)

Is the new patient flow per month sufficient?(Required)

If you are using an intra-oral camera are you entering it as a procedure?

Please send me your P & L reports from January to December of the previous year and year to date this year. / Print a procedure report for the last 12 months. I need to see the individual ADA codes and the number of procedures completed in each category. / Please send me your financial arrangement form you use for communicating out of pocket finances with your patients. / If available send me you Delinquent Accounts Receivable report. / I will need one week’s worth of schedules printed so that I can review how you schedule.*

DOCTOR PROVIDER SCHEDULE: ACCESS TO 2 CHAIRS YET SCHEDULED MOSTLY IN ONE CHAIR?*

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I have read the list of necessary documents above.

I will acquire the documents specified above.

Phone

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