Zuelke & Associates
Phone: 503.723.0200
Email:

Confidential Practice Analysis Form for Orthodontic Practices

Before you begin completing this form, the person responsible for its completion must call our office (503.723.0200) for specific instructions. Not with an orthodontic practice? Please use our general form instead. Thank you!

    *Required fields









    Please supply the following information for the most recent six months.

    1. 1. Total Number of New Patient Exams: Each new patient you have never seen before. All new patient exams count without regard to diagnosis or recall status.
    2. 2. Gross Production: Total fees for all new cases start before subtracting any discounts, adjustments, transfers out, write-offs, etc. Also include any miscellaneous fees such as broken retainers, records, exams, etc.
    3. 3. Adjustments: Any ledger entry that increases or decreases a patient or insurance balance (discounts, refunds, transfers out, write-offs, etc.), other than fees and payments. Please be sure to note whether your Adjustments are a positive (+) or a negative (-) figure.
    4. 4. Gross Collections: Gross payments posted to all accounts before adjustments (this will not be the same number as "deposits.")
    5. 5. Total Number of New Starts: Number of first time starts (Full, Limited, Phase I, TMJ, Functionals, etc.) Do not count patients who have had any form of previous treatment (secondary starts for instance) in your office.


    Month






    1. New
    Exams






    2. Gross Production






    3. Any
    Adjustments






    4. Gross Collections






    5. New
    Starts