Preparatory Analysis
	In order to receive a practice consultation by one of our consultants, please complete the following questionnaire.
	*First Name
	*Surname
	Practice Name
	*Street Address
	*Suburb
	*City
	*State	VIC NSW SA QLD WA ACT TAS NT New Zealand
	*Postcode
	*Country
	*Work Telephone
	*Facsimile No
	Home Telephone
	*Mobile Telephone
	*Email Address		*Required Fields
1.	Years in Practice
2.	What is your monthly production ? (based on an average of your last 3 months)
3.	What is your daily production ? (based on an average of your last 3 months)
4.	Do you schedule your day to day goal ?		Yes No
5.	What is your your daily goal?
6.	What is your collection percentage ?
7.	What is your overhead percentage ?
8.	How many new patients do you see each month on average ?
9.	Do you extend financial arrangements in order to increase case acceptance on comprehensive cases ?		Yes No
10.	How much do you have outstanding in accounts receivable ?
11.	How long is your new patient exam and what is it comprised of ?
12.	Do you diagnose and present quadrant dentistry ?		Yes No
13.	Do you track your case acceptance ?		Yes No
	a) If yes what is it for new patients ?
	b) If yes what is it for existing patients ?
14.	What is the size of your patient base ? (Patients seen within last 18 months)
15.	How many hygiene days do you have per week ?
16.	How far ahead are you booked ?
17. Please list names of your staff, their position, length of employment and the number of hours they work per week. Then, rank each staff member on a scale of 1-10, with 10 being the highest. (You should consider their overall performance, their contribution to the practice and the team participation in determining their rank). Please rank yourself as well. Name Position Length of Employment Hours Rank 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
18.	Are you participating in any reduced fee programmes ?		Yes No
	If yes which ones
19.	How many surgeries do you have in your practice ?
	How many surgeries do you, personally, operate out of each day ?
20.	What is your schedule : when do you work? when is your practice open?
21.	How many hours per week are you booked for:
	a) Production
	b) Staff Meetings
	c) Administration
22.	What is your current net take home pay ?
23.	Is this enough ?		Yes No
	If no, how much more do you need ?
24.	Are you funding your retirement and/or superannuation?		Yes No
	If yes, at what annually ?
25.	When do you plan to retire?
26.	List 3 things in your practice you would like to change.		1 2 3
27.	On a scale of 1-10, with 10 being the highest, where would you rate your management and leadership skills?
	a) I am a good leader		1 2 3 4 5 6 7 8 9 10
	b) My staff know exactly what I expect from them and why it is important		1 2 3 4 5 6 7 8 9 10
	c) I have a Practice Philosophy Statement		1 2 3 4 5 6 7 8 9 10
	d) I have shared my vision of the practice's future with my staff		1 2 3 4 5 6 7 8 9 10
	e) I lead my staff, my staff manage my practice		1 2 3 4 5 6 7 8 9 10
	f) My staff know the daily goal and schedule accordingly		1 2 3 4 5 6 7 8 9 10
	g) I share most of the business figures with my staff		1 2 3 4 5 6 7 8 9 10
	h) Staff have job descriptions		1 2 3 4 5 6 7 8 9 10
	i) Performance reviews are done yearly, not during salary reviews		1 2 3 4 5 6 7 8 9 10
	j) Salary reviews are based on contribution, merit and practice turnover, not on demand		1 2 3 4 5 6 7 8 9 10
	k) My practice has a morning meeting every day		1 2 3 4 5 6 7 8 9 10
	l) My practice has a weekly staff meeting		1 2 3 4 5 6 7 8 9 10
	m) I have an annual plan		1 2 3 4 5 6 7 8 9 10
	n) I have a strategic plan		1 2 3 4 5 6 7 8 9 10