Initial Practice Evaluation Form

Please complete this form for each practice.

Practice Name

Dental Office Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Office Phone

Doctor/Owner Name

First Last

How many years does the Dentist want to stay on?

Doctors Desires

Check all that apply

Exit Plan

Partnership

Multi Locations

Community Involvement

Reputation

Brand Plan

Patient Management Software

Practice Website

Services Offered

First Choice

Second Choice

Third Choice

Average Monthly Revenue

Desired Practice Revenue Goal

Total Number of Dentists

Total Number of Hygienist's

Total Number of Operatories

Doe the practice need staff/ providers?

Check all that apply.

Dentist

Oral Surgeon

Periodontist

Orthodontist

Hygienist

Patient Care Administrator

Dental Assistnat

Office Manager