In order to become better acquainted with your practice, it is important for me to have
some idea about the business portion of it. Below is a survey of specific pieces of
information that will be helpful in creating a clearer picture of your practice for me. If
you do not have the exact number, make the most accurate estimate you can. If this is
also not possible, leave the category blank. Once this survey is complete, please return it
to the PERSPECTIVES address above.
 
 

________ Years of practice's existence ________ Years of private practice (doctor)

________ Number of operatories ________ Number if hours worked/week

________ Number if Chairside Assistants ________ Number of Dental Hygienists

________ Number of Front Office personnel ________ Number of new patients/month

________ Hours/month-- staff meetings ________ Patient visits/day

___________________________ Last 12 months' production (in dollars)

___________________________ Last 12 months' collections (in dollars)

___________________________ Total overhead expenses (in dollars)

___________________________ Type of Retirement Plan (if any)

________  % overhead/staff salaries ________ % overhead/dental supplies

________  % overhead/continuing education ________ % overhead/office supplies
 

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