Complimentary Telephone Consultation Request Form

If you would like to schedule a complimentary telephone conference call, please take a minute to provide us with some background information about you and your practice. Simply fill in this form and click "submit". We will contact you to schedule your telephone conference. Thank you.

Name:

Dental School:

E-mail Address:

Year of Graduation:

GP:

Specialty:

Where do you prefer all correspondence be sent?
(Please complete the appropriate address below)

Home

Office

Home Address

Office Address

Mailing Address:

City:

State:

Zip Code:

Phone:

Fax:

Average number of hours office open per week:

Estimated number of days you practiced this past year:

How long has your practice been established?

Practice is:

Sole Proprietorship

Corporation

Partnership

S Corp

Limited Liability Company

C Corp

2007 Collections:

($)

Overhead Percentage:

Do you own or rent your facility:

Own

Rent

Square Footage of Your Facility:

Number of Operatories:

Number of Hygiene Days per Week:

Number of New Patients per Month:

Number of active patients (i.e., patients who have visited your office for at least one recall visit in the last 18 months):

Please estimate the approximate percentages of the sources of revenue in your practice:

a.	Direct from the patient

b.	PPO’s, DMO’s

c.	Insurance\Indemnity

d.	Other sources (please identify)

What percentage of clinical procedures are referred to area specialists?

Endo:

Ortho:

Implants:

Perio Surgery:

Pedo:

Oral Surgery:

Other:

What would you like to accomplish during our complimentary telephone conference call?

How did you hear about us?

	Web Search
	Consulting Firm
	Journal Ad
	Accountant
	Snyder Group Client
	Dental Supply Company
	Seminar
	Other