| Production Overview |
| 1. Production - less all adjustments |
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2. Collection - less refunds |
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3. Accounts Receivable Balance - please total all 3 months
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Office Hours |
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4. Chairside Hours Worked by Doctor |
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5. Hours Worked by Associate(s) (only include hours of permanent associate(s)) |
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6. Hours Worked by Hygienist(s) |
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7. Doctor Hours for Continuing Education |
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8. Office Hours for Continuing Education |
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9. Office Hours for Staff Meetings
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| Visits |
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10. Total Hygiene Treatment Visits (*See Below) |
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11. Total Client Visits |
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12. New Pedo (0-16 yrs) Private/Insurance Clients |
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13. New Adult Clients Private/Insurance Clients |
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14. New Capitation/PPO and DSHS Clients |
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15. Total New Clients (lines 12 + 13 + 14) |
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16. Emergency Visits
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| Expenses |
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17. Staff Salaries (Gross)
(Do not include lab salaries, Associate salaries, or Dr. salaries. ) |
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18. Dental Lab Expense (include lab salaries) |
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19. Dental Supplies |
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20. Rent, Utilities, Telephone, Janitorial, Parking, Landscaping, Security, Medical Waste, Storage |
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21. Office Supplies, Software, Printing, Postage, Maintenance, Repairs, Bank Charges |
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22. Legal, Accounting, Consulting, Professional Services |
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23. Advertising / Promotion |
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24. Continuing Ed, Meetings, Books/CD's, Meals, Entertainment, Travel, Auto, Licenses, Dues, Subscriptions |
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25. Insurance - Professional, Malpractice, Medical, Disability, Life |
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26. Taxes (business and payroll) |
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27. Associates Salaries
(only include salaries of permanent Associate(s)) |
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28. Miscellaneous Expense - uniforms, laundry, donations |
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29. Equipment Leases |
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30. Bank Payments / Large $$ Equipment (**See below) |
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31. Retirement Contributions / Profit Sharing
(include contributions for Dr. AND staff)
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Operatories |
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32. Operatories
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Chairside Personnel |
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33. Chairside Personnel
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Desk Personnel |
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34. Desk Personnel
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Active Clients (4th quarter only) |
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35. Active Clients (***See below) |
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* Line #10: For this category, report only adult prophy D1110, pedo prophy D1120, perio maintenance D4910, curettage/root planing D4341, partial quad scale/root planing D4342, full mouth debridement D4355. Count daily visits regardless of who did treatments.
Line #30: **Major dental equipment, office equipment, or leasehold improvements purchased and paid in cash should be included in bank payments for that quarter(s).
Line #35: ***An active client is one who has been in for hygiene or restorative treatment in the last 24 months. Do not count one-time emergency visits. |
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Comments
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