CONTACT INFO
Doctor/Owner's First Name
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Doctor/Owner's Last Name
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Doctor/Owner Email
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Doctor/Owner Cell Phone
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PRACTICE INFO
Practice Name
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Street Address
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State
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City
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Postal code
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Website
Practice Phone
Office Email
Who is your Case Presenter?
Who is your Office Manager?
Who referred you to Energize Group?
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Is your practice open?
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Yes
No
If yes, what year did you open?
If no, when will you open?
Practice Management System
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The following platforms/systems are set up
Dental Intel Analytics
Dental Intel Engagement
LocalMed
Kleer
Dental Menu
Other Software Used in Office
Do you currently have a membership program in place?
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Yes
No
Financing Options
CareCredit
Sunbit
Cherry
Lending Club
Proceed
DocPay
HFD
Other Financing Options
What kind of marketing have you done in the past?
What kind of marketing are you currently doing?
How do you want to position yourself in the market (luxury, family-friendly, high-tech, budget-friendly, etc.)?
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Top 3 Services you want to be known for (or advertise for?) in your area?
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How many operatories do you have?
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What age range of patients do you see?
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Do you have any ongoing or upcoming special promotions, events, or campaigns your marketing should focus on?
What type of practice are you?
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Services Offered:
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Implants
Implant Bridges
All on 4's
Crowns
Extractions
Bridges
Partials
Snap in Dentures
Traditional Dentures
Braces
Invisalign
Clear Aligners
Veneers
IV Sedation
Nitrous Sedation
Oral Sedation
New Patient Special
Hygiene
Membership Program
Pediatric Dentistry
TMJ
Whitening: In Office Bleaching
Whitening: Trays
Emergency
Root Canal
Laser Dentistry
PRACTICE GOALS
Monthly New Patients (Current vs Goal)
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Monthly Collections (Current vs Goal)
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Other Practice Goals
A2P BUSINESS REGISTRATION
Legal Business Name
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Full Legal Address
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Entity Type
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LLC
Corporation
PLLC
Partnership
Sole Proprietorship
EIN #
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Does you have a privacy policy linked on your website? We will need this prior to launch.
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Yes
No, need to add one.
INSURANCE INFORMATION
What are your hours of operation? Specifiy if you take lunches also
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Do you offer same day appointments?
Which PPO's are you in Network with?
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Do you accept Out of Network PPOs?
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If you only take some PPO's, which ones?
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Are you a DMO provider? If so, which ones?
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Are you a HMO provider? If so, which ones?
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Are you okay with a translator at the appointment and the use of Google Translate?
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Does your office speak spanish?
Do you accept medicare
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Medicare Plans you Accept
Do you accept medicaid
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Medicaid Plans you Accept
If you don't accept medicaid and medicare, should we still try and book them a consultation?
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Medicaid & Medicare Notes
Do you have an after hours forwarding voicemail or phone line? If not, how would you like us to direct patients in emergency situations?
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Are you equipped to handle special needs patients?
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