To receive a complimentary overview of your practice's status and statistics, print this page and fax  to 301-695-7624. 

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PRACTICE/HYGIENE ANALYSIS FORM

Vision of Practice Defined? Yes  No  

Mission and Purpose? Yes  No   

Goals set?   Yes  No               

 Operatories: Total    Doctor   Hygiene   Other        

 Are they equally equipped: Yes  No               

 Staff Size: Hygienists  CDA’s   DA’s  

Office Admin.      Other          

 What style of practice do you have? 

What percentage of your practice are children?                 

 Do you accept any HMO/reduced fee?  Yes  No 

What are the percentages?  HMO     PPO        

 Traditional third-party   Fee for Service       

 How many patients (Seen in hygiene within the last year) do you have in your practice?                     

 When did you last complete a chart audit?  

How many total Hygiene days per week?  (Count two hygienists on one day as two days)

 On the average, how many patients do
your hygienists see per day?            

 Are you scheduling on a 10 or 15 minute unit?                

 Are cancellations and failures an issue in the hygiene schedule? Yes  No   Doctor’s? Yes  No  To what degree?

How many adult new patients
do you see per month on average?      

 Does the hygienist see new patients?   Yes  No                           

 What was the date of your last fee increase?

 How often do you take Bitewings?   Panorex   

FMX

Do you have a radiographic policy?  Yes  No                                 

 What is the average monthly production in Hygiene?  $ 

Doctor?  $

Does this production include exam in Hygiene or Doctor totals? Yes  No 

How are your Hygienists paid?

Reviewing your procedure analysis report, how many of the following procedures have been performed year to date?

 Who is in charge of the Recare program?