Consulting
Technology
Software Implementation
360Care
Gaidge
Events
Our Team
Contact Us
impact360 Orthodontic Consultants
Orthodontic Practice Management Consulting • Software Implementation • Technology Solutions
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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?
Email
This field is for validation purposes and should be left unchanged.
This iframe contains the logic required to handle AJAX powered Gravity Forms.
web development by David Sullivan