Practice Name

Specialty

City, State

Phone

Office Survey

To assist us in providing the best service to you and your patients, please fill out our office survey.

Office Survey

Dear Colleagues and Teams,

We invite you to share about your office in hopes that knowing you better will increase our ability to serve you and your patients at a higher level and make referrals seamless.

About Your Practice

Practice Name:    More than one location?   Yes    No

Phone Number:    Fax Number:

Primary Practice Address

Street Address:

City, State ZIP:

Second Practice Address (If Applicable)

Street Address:

City, State ZIP:

Email

Practice Email:

Yes. I would like to receive case reports of my patients electronically.

Practice Website:

Office Hours:

Dentist (Owner):     Assoc:

Office Manager:     No. on Team:

Coordinating our Services

Please list the top four insurance companies that you provide service for:

  1.     HMO  PPO   Both
  2.     HMO  PPO   Both
  3.     HMO  PPO   Both
  4.     HMO  PPO   Both

Does your practice offer an in house dental plan for patients?     Yes     No

Does the practice offer third party financing?     Yes     No

If yes, with which companies?
CareCredit  Wells Fargo  Citi-Bank   

Does the practice offer nitrous oxide?   Yes    No

Additional Comments:

Thank you for taking a moment to help convey vital knowledge for your practice that will aid is in serving your patients and your dental team to the best of our ability.