First Name

Last Name

Practice Name

Practice Type

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Email

Phone Number

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Practice Zip Code

What prompted you to get your Score?

In one sentence, how would you describe your practice to a new acquaintance?

Would you say that your practice is:

Please estimate what percentage of patients would say they are “very satisfied” with your practice/team/care:

On average, how many referrals from patients do you get each month?

In the last 12 months, what proportion of your patients complained in writing (by email, letter, website submission, or online review)?

Estimate your ratio of cash paying patients who do NOT use insurance vs. insurance-driven patients (capitation, PPO, HMO, other):

What percentage of your CASH patients are on a monthly subscription payment model (sometimes called an in-house membership club) for preventive care?

Rate the effectiveness of your hygiene department on a scale of 1-5

Rate the effectiveness of your dental assistants on a scale of 1-5

Rate the effectiveness of your front desk and administrative personnel on a scale of 1-5

In the next 12 months, do you expect your revenue to:

In the last 12 months, what percentage of your patients who needed treatment would you estimate accepted “ideal treatment”?

Which of the following would you say best describes your team:

If you could achieve just ONE of the following goals in the next 12 months, which one would it be?

Who would you be most likely to turn to for advice on building the value of your practice? (Check all that apply.)

Which of the following describes what you perceive as the current greatest obstacle to building the practice of your dreams? (check all that apply)

Which of the following best describes what you look for in an adviser?

What was your profit margin for the most recent completed financial year?

What was your practice's annual revenue in the last 12 months?

How many full-time equivalent doctors currently work in the practice?

When comparing your most recently completed financial year to the previous year, did your revenue:

Which of the following statements best describes your current cash needs:

Please rate your social media influence by estimating the number of reviews you currently have on Google:

Year in which you were born

Average MONTHLY collections

Average MONTHLY number of new patients:

Average ANNUAL investment in business development and marketing:

Would you like a comprehensive analysis of how your practice is performing in FOUR key drivers of practice value and how to improve it?

What is the best phone number to contact you?