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
Please select the scenario that best describes your practice.
6 Month Recall Visit
3rd Visit (1st Visit of the Second Year)
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 firstname.lastname@example.org
Is there anything else about your preventive services or patient experience that you would like us to know?