New Client Assessment

(Be assured this information will remain completely confidential.)

Your name*

Your email*

Doctor's Name

Practice Name

Mailing Address

City, State, Zip

Telephone

Website

How were you introduced to Kathryn and/or PerioLinks?

What is the nature of your practice? (Family practice, specialist, group practice, etc.)

What are the top two challenges with your hygiene department?

What methods have you used so far to overcome those challenges?

What would you like to accomplish with the hygiene department as a result of working together?

What would you like to have accomplished one year from now?

List each hygienist and number of days worked weekly:

Provide number of procedures by code performed in the last year:

D1110:

D4341:

D4342:

D4910: