Page title

First Name

Last Name

Approximate total office production last 12 months:

Approximate production adjustments last 12 months due to PPO contracts?

Approximate total accounts receivable (All money owed to your practice)

What is your retirement goal (dollar amount)?

How much have you put away for retirement so far (dollar amount)?

What are the 3 biggest obstacles preventing you from achieving your goals?

Roughly how many outside referrals per month do you make to:

Endo

Perio

Ortho

Roughly what percentage of your adults receive & pay for Fluoride?

Roughly how many new patients do you see per month?

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