Client Survey

Please take a few moments to complete our survey. The information that you share with us is privileged and confidential and will be used to develop an agenda for our visit.

Practice Name*
Orthodontist(s)*
Name # Years in Practice
CONTACT INFORMATION
Main Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Main Office Phone*
Main Office Back Line
Main Office FAX
Primary Email Address
Website
Personal Information
Name Email

Please provide the email address of any doctor who would like to be sent follow‐up information.
PRACTICE INFORMATION
Offices
Location Days Per Month Distance from Main Office Connection Type Connection Speed

If you have multiple office locations, please list and describe the method by which they are connected (DSL, cable modem, T1 line, etc.) and speed of that connection (1 MG upload / 4 MG download). Start with the Main office.
Does all staff travel with doctor(s)? If not, describe:*
Are multiple offices open at the same time in terms of seeing patients?
Is the main office always staffed?
Are satellite offices always staffed?
ADMINISTRATIVE STAFF
Position / Title Staff Member Name # Years in Practice

List positions including Office Manager, Treatment Coordinator, Scheduling Coordinator, Insurance Coordinator, and Financial Coordinator.
Do you use a bookkeeper or an accounting firm for the following services?
Bank Reconciliation
- Yes
- No
Payroll
- Yes
- No
Paying Bills
- Yes
- No
Monthly Bookkeeping
- Yes
- No
Tax Preparation
- Yes
- No
CLINICAL STAFF
Position / Title Staff Name # Years in Practice

List clinical positions including Clinical Coordinator, Clinical Assistant/RDA, Lab Technician, and Records Technician.
TREATMENT MECHANICS
Type of Bracket:
Bonding Method:
- Direct
- Indirect
Do you use a digital model service?
- Yes
- No
Rotation interval (weeks) between visits:
SOFTWARE
Which Practice Management software (Orthotrac, Dolphin, Ortho II, Tops, etc.) do you use and what is the current version?
Please check the additional software packages that you are using:
- Communications
- Electronic Charting
- Patient Flow
- Electronic Insurance Claims
- Electronic Statements
- Collections
- ACH / Credit Card Drafting
- Pearl
- Aquarium
- IACT Presentation Software
- Televox
- Sesame
- DemandForce
- ZACC
- OrthoBanc
- Quicken/QuickBooks
Other Software:
IMAGING
Which Digital Imaging system do you use and what is the current version?
Are you using digital radiography? If so, who is the manufacturer?
If you have satellite offices, to what extent do you use digital radiography in those offices?
Do you download photographs in satellite offices?
- Yes
- No
What digital camera are you using?
Do you print letters in satellite offices?
- Yes
- No
Are you using 3D technology? If so, please describe:
Do you plan to integrate 3D technology into your practice in the next three years?
- Yes
- No
HARDWARE / TECHNOLOGY
Technical Engineers / Company / Individuals that support your hardware and network:
Individual or Company Name Phone # Are you pleased with their services?
FINANCIAL INFORMATION
*Please send current fee sheet
FEES
Phase I
Child Full
Adult Full
Invisalign
Net production this year:
Previous year end:
Net collection this year:
Previous year end:
# of exams this year:
Previous year end:
# of starts this year:
Previous year end:
# of debands this year:
Previous year end:
Do you accept insurance assignment?
- Yes
- No
Are you a PPO or HMO provider?
- Yes
- No
MISCELLANEOUS
Why did you contact impact360?
How did you hear about impact360?
Have you worked with other consultants? Are you currently working with other consultants?
Are you a member of a professional study club? If so, please list name of study club.
What are the three most challenging issues your practice faces?
What are your consulting goals?
Phone
This field is for validation purposes and should be left unchanged.

impact360 Orthodontic Consultants

Orthodontic Practice Management Consulting • Software Implementation • Technology Solutions

Client Survey

CONTACT INFORMATION

PRACTICE INFORMATION

SOFTWARE

IMAGING

HARDWARE / TECHNOLOGY

FINANCIAL INFORMATION

MISCELLANEOUS

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