National Dental Placements Sponsor

In order to familiarize us with your practice, as well as enable us to market the opportunity in your practice as effectively as possible, please fill out the following questionnaire thoroughly and completely. Once we have your information on file, we will be happy to market your practice on our website free of charge.

General Information

We respect your privacy! Personally identifiable information provided to us in this section is not displayed on the web site. Contact and financial information is requested for NDP internal reference only.
Practice name :
Client name :
Practice address :
 
City, state, ZIP :
Office phone :
Office fax :
Email Address :
 
Name and title of primary person for NDP to contact in office :
 
 
Candidate Information
What is your ideal time frame to bring in a new doctor? :
 
How would you describe the type of person that you are seeking for the opportunity in your practice? :
 
 
Practice information
Year established :
Practice type :
Clinical focus :
Building type : (i.e. Stand Alone, Business Complex, etc..)
Office space : Square Feet
Please make note of any other key points of interest about the location of your practice :
 
Facility :
Number of doctor chairs in your office :
Number of hygiene chairs :
Please list all staff in your office (i.e. 2 Hygienists, 3 Assistants, etc.) :
 
Please describe the technology and equipment in your practice (i.e. CEREC, paperless, etc.) :
 
Please describe any recent updates to your building, technology, staff, etc. :
 
 
Practice Performance
Please estimate percentage of production for the areas listed :
Procedures
Hygiene : %   Endodontics : %
Orthodontics : %   Restorative : %
Periodontics : %   Oral Surgery : %
Crown & Bridge : %   Prosthodontics : %
Children : %   Other : %
Patients :
Patients seen in the past year :
Total number of patients seen last month :
New patients seen last month :
Production
(if applicable)
Total monthly office production : $
Total monthly doctor production : $
Total monthly hygiene production : $
Monthly production per doctor (if applicable) :
Dr.   $
Dr.   $
Dr.   $
Dr.   $
Dr.   $
Overhead : %
Total days worked by all doctors (2007) :
Total days worked by hygienists (2007) :
How far out is doctor production booked? :
 
What procedures are referred out? :
 
Marketing :
Yellow Pages Display Ad
Yellow Pages Listing Only
Direct Mail / Valupak
TV / Radio ads
Website / Internet ads
Other
 Check all marketing stategies that you have used in the past three months
How would you describe your practice? :
 
Tell us about yourself.
Please provide some biographical information about yourself, such as where you went to dental school, why you chose your career path, your hobbies or anything else that you would like to add.
 


After completing this form, please email 3-10 digital pictures of your office (both inside and out) to jake@nationaldentalplacements.com
Call the industry's leading recruitment firm today at (866) 944-8304

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