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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
County Dental
Harbor Point
Existing Identity
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
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