Practice Questionnaire

1Unique Practice Identifier

2Introductory Background

3Practice Background

4Premises

5Practice Hours and Staff Information

6Office Closures and Staff Benefits

7Patient Base Information

8Pricing Approach and Services/Treatments Provided

9Asset Details

10Additional Information

Unique ID for Web Questionnaire

Practice Hours and Staff Information

Office Hours (Monday)

Office Hours (Tuesday)

Office Hours (Wednesday)

Office Hours (Thursday)

Office Hours (Friday)

Office Hours (Saturday)

Office Hours (Sunday)

For associates only, how are they compensated? (please select one or more)

Dental Billings

Recall Exams

Recall Radiography

In-House Lab Fees

Staff Lunch Hours

Staff

Lunch Period (Owners)

Lunch Period (Associates)

Lunch Period (Hygienists)

Paid Lunch Period (Hygienists)

Lunch Period (Receptionists/Administrative Staff)

Paid Lunch Period (Receptionists/Administrative Staff)

Lunch Period (Chairside Assistants)

Paid Lunch Period (Chairside Assistants)

Practice Hours and Staff Information Additional Notes

Employee Information

Provider / Employee Type (1)

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Position Title (1)

First Name (1)(Required)

Last Name (1)

Dental Specialty (1)

Dental Compensation % (1)

Hygiene Compensation % (1)

Salary / Wage (1)

Salary / Wage per ________ (1)

Year Hired (1)

Vacation weeks (1)

Vacation Pay % (1)

Signed Contract (1)

Are they On Disabilty or Sick Leave ? (1)

Day/Hours Worked

Monday (1)

Select

Monday Hours Start (1)

Monday Hours End (1)

Tuesday (1)

Select

Tuesday Hours Start (1)

Tuesday Hours End (1)

Wednesday (1)

Select

Wednesday Hours Start (1)

Wednesday Hours End (1)

Thursday (1)

Select

Thursday Hours Start (1)

Thursday Hours End (1)

Friday (1)

Select

Friday Hours Start (1)

Friday Hours End (1)

Saturday (1)

Select

Saturday Hours Start (1)

Saturday Hours End (1)

Sunday (1)

Select

Sunday Hours Start (1)

Sunday Hours End (1)

Irregular Schedule Notes (1)

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Provider / Employee Type (2)

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Position Title (2)

First Name (2)(Required)

Last Name (2)

Dental Specialty (2)

Dental Compensation % (2)

Hygiene Compensation % (2)

Salary / Wage (2)

Salary / Wage per ________ (2)

Year Hired (2)

Vacation weeks (2)

Vacation Pay % (2)

Signed Contract (2)

Are they On Disabilty or Sick Leave ? (2)

Day/Hours Worked

Monday (2)

Select

Monday Hours Start (2)

Monday Hours End (2)

Tuesday (2)

Select

Tuesday Hours Start (2)

Tuesday Hours End (2)

Wednesday (2)

Select

Wednesday Hours Start (2)

Wednesday Hours End (2)

Thursday (2)

Select

Thursday Hours Start (2)

Thursday Hours End (2)

Friday (2)

Select

Friday Hours Start (2)

Friday Hours End (2)

Saturday (2)

Select

Saturday Hours Start (2)

Saturday Hours End (2)

Sunday (2)

Select

Sunday Hours Start (2)

Sunday Hours End (2)

Irregular Schedule Notes (2)

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Provider / Employee Type (3)

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Position Title (3)

First Name (3)(Required)

Last Name (3)

Dental Specialty (3)

Dental Compensation % (3)

Hygiene Compensation % (3)

Salary / Wage (3)

Salary / Wage per ________ (3)

Year Hired (3)

Vacation weeks (3)

Vacation Pay % (3)

Signed Contract (3)

Are they On Disabilty or Sick Leave ? (3)

Day/Hours Worked

Monday (3)

Select

Monday Hours Start (3)

Monday Hours End (3)

Tuesday (3)

Select

Tuesday Hours Start (3)

Tuesday Hours End (3)

Wednesday (3)

Select

Wednesday Hours Start (3)

Wednesday Hours End (3)

Thursday (3)

Select

Thursday Hours Start (3)

Thursday Hours End (3)

Friday (3)

Select

Friday Hours Start (3)

Friday Hours End (3)

Saturday (3)

Select

Saturday Hours Start (3)

Saturday Hours End (3)

Sunday (3)

Select

Sunday Hours Start (3)

Sunday Hours End (3)

Irregular Schedule Notes (3)

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Provider / Employee Type (4)

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Position Title (4)

First Name (4)(Required)

Last Name (4)

Dental Specialty (4)

Dental Compensation % (4)

Hygiene Compensation % (4)

Salary / Wage (4)

Salary / Wage per ________ (4)

Year Hired (4)

Vacation weeks (4)

Vacation Pay % (4)

Signed Contract (4)

Are they On Disabilty or Sick Leave ? (4)

Day/Hours Worked

Monday (4)

Select

Monday Hours Start (4)

Monday Hours End (4)

Tuesday (4)

Select

Tuesday Hours Start (4)

Tuesday Hours End (4)

Wednesday (4)

Select

Wednesday Hours Start (4)

Wednesday Hours End (4)

Thursday (4)

Select

Thursday Hours Start (4)

Thursday Hours End (4)

Friday (4)

Select

Friday Hours Start (4)

Friday Hours End (4)

Saturday (4)

Select

Saturday Hours Start (4)

Saturday Hours End (4)

Sunday (4)

Select

Sunday Hours Start (4)

Sunday Hours End (4)

Irregular Schedule Notes (4)

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Provider / Employee Type (5)

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Position Title (5)

First Name (5)(Required)

Last Name (5)

Dental Specialty (5)

Dental Compensation % (5)

Hygiene Compensation % (5)

Salary / Wage (5)

Salary / Wage per ________ (5)

Year Hired (5)

Vacation weeks (5)

Vacation Pay % (5)

Signed Contract (5)

Are they On Disabilty or Sick Leave ? (5)

Day/Hours Worked

Monday (5)

Select

Monday Hours Start (5)

Monday Hours End (5)

Tuesday (5)

Select

Tuesday Hours Start (5)

Tuesday Hours End (5)

Wednesday (5)

Select

Wednesday Hours Start (5)

Wednesday Hours End (5)

Thursday (5)

Select

Thursday Hours Start (5)

Thursday Hours End (5)

Friday (5)

Select

Friday Hours Start (5)

Friday Hours End (5)

Saturday (5)

Select

Saturday Hours Start (5)

Saturday Hours End (5)

Sunday (5)

Select

Sunday Hours Start (5)

Sunday Hours End (5)

Irregular Schedule Notes (5)

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Provider / Employee Type (6)

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Position Title (6)

First Name (6)(Required)

Last Name (6)

Dental Specialty (6)

Dental Compensation % (6)

Hygiene Compensation % (6)

Salary / Wage (6)

Salary / Wage per ________ (6)

Year Hired (6)

Vacation weeks (6)

Vacation Pay % (6)

Signed Contract (6)

Are they On Disabilty or Sick Leave ? (6)

Day/Hours Worked

Monday (6)

Select

Monday Hours Start (6)

Monday Hours End (6)

Tuesday (6)

Select

Tuesday Hours Start (6)

Tuesday Hours End (6)

Wednesday (6)

Select

Wednesday Hours Start (6)

Wednesday Hours End (6)

Thursday (6)

Select

Thursday Hours Start (6)

Thursday Hours End (6)

Friday (6)

Select

Friday Hours Start (6)

Friday Hours End (6)

Saturday (6)

Select

Saturday Hours Start (6)

Saturday Hours End (6)

Sunday (6)

Select

Sunday Hours Start (6)

Sunday Hours End (6)

Irregular Schedule Notes (6)

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Provider / Employee Type (7)

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Position Title (7)

First Name (7)(Required)

Last Name (7)

Dental Specialty (7)

Dental Compensation % (7)

Hygiene Compensation % (7)

Salary / Wage (7)

Salary / Wage per ________ (7)

Year Hired (7)

Vacation weeks (7)

Vacation Pay % (7)

Signed Contract (7)

Are they On Disabilty or Sick Leave ? (7)

Day/Hours Worked

Monday (7)

Select

Monday Hours Start (7)

Monday Hours End (7)

Tuesday (7)

Select

Tuesday Hours Start (7)

Tuesday Hours End (7)

Wednesday (7)

Select

Wednesday Hours Start (7)

Wednesday Hours End (7)

Thursday (7)

Select

Thursday Hours Start (7)

Thursday Hours End (7)

Friday (7)

Select

Friday Hours Start (7)

Friday Hours End (7)

Saturday (7)

Select

Saturday Hours Start (7)

Saturday Hours End (7)

Sunday (7)

Select

Sunday Hours Start (7)

Sunday Hours End (7)

Irregular Schedule Notes (7)

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Provider / Employee Type (8)

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Position Title (8)

First Name (8)(Required)

Last Name (8)

Dental Specialty (8)

Dental Compensation % (8)

Hygiene Compensation % (8)

Salary / Wage (8)

Salary / Wage per ________ (8)

Year Hired (8)

Vacation weeks (8)

Vacation Pay % (8)

Signed Contract (8)

Are they On Disabilty or Sick Leave ? (8)

Day/Hours Worked

Monday (8)

Select

Monday Hours Start (8)

Monday Hours End (8)

Tuesday (8)

Select

Tuesday Hours Start (8)

Tuesday Hours End (8)

Wednesday (8)

Select

Wednesday Hours Start (8)

Wednesday Hours End (8)

Thursday (8)

Select

Thursday Hours Start (8)

Thursday Hours End (8)

Friday (8)

Select

Friday Hours Start (8)

Friday Hours End (8)

Saturday (8)

Select

Saturday Hours Start (8)

Saturday Hours End (8)

Sunday (8)

Select

Sunday Hours Start (8)

Sunday Hours End (8)

Irregular Schedule Notes (8)

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Provider / Employee Type (9)

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Position Title (9)

First Name (9)(Required)

Last Name (9)

Dental Specialty (9)

Dental Compensation % (9)

Hygiene Compensation % (9)

Salary / Wage (9)

Salary / Wage per ________ (9)

Year Hired (9)

Vacation weeks (9)

Vacation Pay % (9)

Signed Contract (9)

Are they On Disabilty or Sick Leave ? (9)

Day/Hours Worked

Monday (9)

Select

Monday Hours Start (9)

Monday Hours End (9)

Tuesday (9)

Select

Tuesday Hours Start (9)

Tuesday Hours End (9)

Wednesday (9)

Select

Wednesday Hours Start (9)

Wednesday Hours End (9)

Thursday (9)

Select

Thursday Hours Start (9)

Thursday Hours End (9)

Friday (9)

Select

Friday Hours Start (9)

Friday Hours End (9)

Saturday (9)

Select

Saturday Hours Start (9)

Saturday Hours End (9)

Sunday (9)

Select

Sunday Hours Start (9)

Sunday Hours End (9)

Irregular Schedule Notes (9)

This field is hidden when viewing the form

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Provider / Employee Type (10)

This field is hidden when viewing the form

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Position Title (10)

First Name (10)(Required)

Last Name (10)

Dental Specialty (10)

Dental Compensation % (10)

Hygiene Compensation % (10)

Salary / Wage (10)

Salary / Wage per ________ (10)

Year Hired (10)

Vacation weeks (10)

Vacation Pay % (10)

Signed Contract (10)

Are they On Disabilty or Sick Leave ? (10)

Day/Hours Worked

Monday (10)

Select

Monday Hours Start (10)

Monday Hours End (10)

Tuesday (10)

Select

Tuesday Hours Start (10)

Tuesday Hours End (10)

Wednesday (10)

Select

Wednesday Hours Start (10)

Wednesday Hours End (10)

Thursday (10)

Select

Thursday Hours Start (10)

Thursday Hours End (10)

Friday (10)

Select

Friday Hours Start (10)

Friday Hours End (10)

Saturday (10)

Select

Saturday Hours Start (10)

Saturday Hours End (10)

Sunday (10)

Select

Sunday Hours Start (10)

Sunday Hours End (10)

Irregular Schedule Notes (10)

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Provider / Employee Type (11)

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Position Title (11)

First Name (11)(Required)

Last Name (11)

Dental Specialty (11)

Dental Compensation % (11)

Hygiene Compensation % (11)

Salary / Wage (11)

Salary / Wage per ________ (11)

Year Hired (11)

Vacation weeks (11)

Vacation Pay % (11)

Signed Contract (11)

Are they On Disabilty or Sick Leave ? (11)

Day/Hours Worked

Monday (11)

Select

Monday Hours Start (11)

Monday Hours End (11)

Tuesday (11)

Select

Tuesday Hours Start (11)

Tuesday Hours End (11)

Wednesday (11)

Select

Wednesday Hours Start (11)

Wednesday Hours End (11)

Thursday (11)

Select

Thursday Hours Start (11)

Thursday Hours End (11)

Friday (11)

Select

Friday Hours Start (11)

Friday Hours End (11)

Saturday (11)

Select

Saturday Hours Start (11)

Saturday Hours End (11)

Sunday (11)

Select

Sunday Hours Start (11)

Sunday Hours End (11)

Irregular Schedule Notes (11)

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Provider / Employee Type (12)

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Position Title (12)

First Name (12)(Required)

Last Name (12)

Dental Specialty (12)

Dental Compensation % (12)

Hygiene Compensation % (12)

Salary / Wage (12)

Salary / Wage per ________ (12)

Year Hired (12)

Vacation weeks (12)

Vacation Pay % (12)

Signed Contract (12)

Are they On Disabilty or Sick Leave ? (12)

Day/Hours Worked

Monday (12)

Select

Monday Hours Start (12)

Monday Hours End (12)

Tuesday (12)

Select

Tuesday Hours Start (12)

Tuesday Hours End (12)

Wednesday (12)

Select

Wednesday Hours Start (12)

Wednesday Hours End (12)

Practice Questionnaire

Additional Owner Details

Practice Background

Premises

If you lease the premises

If you own your premises

Practice Hours and Staff Information

Staff Lunch Hours

Employee Information

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