Preventive Services Survey

Preventive Services Survey

Preventive Services Survey

In order to create a smart dental savings plan for your office, we start by evaluating your New Patient visit and 6-month follow-up visit. We also look at the patient's second year in your practice to be sure we design a plan that encourages retention.

Please complete the following form to help us get started!

Please list your standard fee for all service you actually bill the patient at a first time visit. For example, if you take a pano and an FMX but only bill the patient for one, please enter "$0" for the service you do not charge. If you do not usually perform the listed service, please check the box "N/A" instead of adding a dollar amount. You are able to add additional services and add your comments if you have additional information we should know.
New Patient Visit

D0150
$
Comprehensive Exam

D0210
$
FMX

D0330
$
Pano

D1110
$
Prophy

D1206
$
Fluoride

Other
$

Please select the scenario that best describes your practice.

6 Month Recall Visit

D0120
$
Periodic Exam

D1110
$
Prophy

D0274
$
4 BWX

D1206
$
Fluoride

Other
$

3rd Visit (1st Visit of the Second Year)

D0120
$
Periodic Exam

D1110
$
Prophy

D0274
$
4 BWX

D1206
$
Fluoride

Other
$

Please select the option that best describes your perio program.
Please select the option that best describes your patient base.
Please upload your current standard fee schedule. File Upload (PDF, JPG, EXCEL, WORD ) or email it to support@smilemore.marketing
Maximum upload size: 2.1MB

Is there anything else about your preventive services or patient experience that you would like us to know?

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