First Name
Last Name
Email Address
Phone
City
State / Province
How long have you been practicing dentistry? How many more years do you plan to practice?
How many team members do you have (Associates; Hygienists; Dental Assistants; Office Manager; Admin)?
How many active patients do you currently have in your practice?
On average; how many new patients do you get per month?
Have you seen a change in case acceptance recently?	Yes No
Has it increased or decreased?	Increased Decrased Stayed the same
What percentage of your day are you spending on daily operations vs. dentistry?
On a scale of 1 to 10, how would you rate your level of stress in relation to your daily operations?	10 (very stressful) 9 8 7 6 5 4 3 2 1 (not stressful)
If there were 2 things you could change about your practice; what would they be?
What part of having a dental practice do you like the best?
What part of having a dental practice do you like the least?
Have you worked with a practice management consultant/coach in the past?	Yes No
Are you currently working with a practice consultant/coach?	Yes No
What is the best day and/or time for us to reach you to discuss your responses?