New Client Questionnaire

Please take a few minutes to fill out this form to contact Developmental Dental Strategies about our consulting programs.

Doctor's Name
Telephone Number
Email Address
Solo Practice or Associates
How long in Practice
How many days work a week
Number of Staff
Business Staff
Assistants
Hygienists
Clinical Coordinators
Other
Computerized?
Computer Software
Terminals in the Ops?
Scheduling on the System
Is Business Staff Scheduling?
Is Clinical Staff?
Is Hygienist?
Average Monthly Production (optional)
Average Monthly Collections (optional)
Percentage
Accounts Receivable Balance (optional)
Active Patient Base
Hygiene Production (optional)
Member of Insurance Plans
Accepting Assignment of Benefits?
Three Major Problem Areas (optional)

Developmental Dental Strategies
3481 Raleigh Dr., Winter Haven, Florida 33884
Phone: 866-862-7875 | Fax: 209-391-3273