PLEASE FILL OUT THE FORM BELOW. You may upload the form on our contact page or have the form ready during your consultation. You may also fax the form to +1 (610) 465-9711.

MM slash DD slash YYYY
Please List Your Provider Team’s Hours:
Doctor and Hygiene Provider Productivity Report: (Total Amount Produced Per Provider in the Last Twelve Months)*
Document the number of procedures performed in the below individual hygiene procedure codes for the last twelve months:
Max. file size: 100 MB.
Does the practice have a documented financial policy? Please attach a copy
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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This field is for validation purposes and should be left unchanged.