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!

Practice Name *

Email Address of Person Completing This Form *

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

$

Comprehensive Exam

Not Performed

D0210

FMX

$

FMX

Not performed

D0330

Pano

$

Pano

Not Performed

D1110

Prophy

$

Prophy

Not Performed

D1206

Fluoride

$

Fluoride

Not Performed

Other

$

Please select the scenario that best describes your practice.

Fluoride is optional but offered to our adult patients at each preventive visit.

Fluoride is always administered to adult patients one time per year.

Fluoride is always administered to adult patients twice per year.

Comments

6 Month Recall Visit

D0120

Periodic Exam

$

Periodic Exam

Not Performed

D1110

Prophy

$

Prophy

Not Performed

D0274

4 BWX

$

4 BWX

Not Performed

D1206

Fluoride

$

Fluoride

Not Performed

Other

$

Comments

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

D0120

Periodic Exam

$

Periodic Exam

Not Performed

D1110

Prophy

$

Prophy

Not Performed

D0274

4 BWX

$

4 BWX

Not Performed

D1206

Fluoride

$

Fluoride

Not Performed

Other

$

Comments

Please select the option that best describes your perio program.

Very few of our patients are treated for periodontal disease.

About 10% of our patients receive perio-maintenance (D4910).

About 20% of our patients receive perio-maintenance (D4910).

About 30% of our patients receive perio-maintenance (D4910).

About 40% of our patients receive perio-maintenance (D4910).

50% or more of our patients receive perio-maintenance (D4910).

Please select the option that best describes your patient base.

We see very few children in our practice.

About 10% of our patient base is represented by families with children.

About 25% of our patient base is represented by families with children.

50% or more of our patient base is represented by families with children.

Please upload your current standard fee schedule. File Upload (PDF, JPG, EXCEL, WORD ) or email it to support@smilemore.marketing

Maximum file size: 50MB

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

Comments

reCAPTCHA