Practice Assessment Form | Elevate Endo Workshop

Step 1 of 14

Practice Assessment Application

Let's start with you.

Tell us a bit about yourself and your practice before we dive into the details. After checkout is complete, your assessment will be completed in approximately 3-4 weeks after which you will be contacted to schedule your video call with Dr. Carruth.

First Name

Last Name

Years in Specialty Practice

Last Year's Annual Collections ($)

Step 2 of 14

Insurance Networks

How many insurance networks is your practice currently contracted with? List each insurance company you are contracted with and their approximate share of collections. If you are out of network put “0” in the write-offs section and click continue.

Number of Insurance Contracts

Are you willing to terminate one or more insurance contracts if needed to accomplish your profitability goals?

Step 3 of 14

Provider Type

Please answer both questions below.

Are you a Medicaid provider?

Are you a Medicare provider?

Building Stage

Congratulations — you're in the Building Stage!

There is so much excitement and growth potential ahead of you. Unfortunately, based on the responses you have provided, your practice does not meet the requirements for our workshop (yet!). To help you keep moving in the right direction, we are providing our Profitability Map as a free gift to you.

Just click the link below to download the PDF and check back in with us once you've built up your practice a bit more. Keep doing high quality work and strengthening your reputation with your referring dentists. We look forward to working with you then!

Download Free Profitability Map →

Great Fit

Your practice sounds like an excellent fit.

Congratulations — your practice meets the requirements for a Practice Assessment with Dr. Carruth. To move forward, please complete the remaining practice questionnaire as well as the checkout process for full payment. After checkout is complete, you will be able to sign up for your video call time and date with Dr. Carruth.

Step 4 of 14

Contact Information

How do we reach you?

We'll use your direct contact for all assessment communications.

Your Direct Contact

Direct Email

Direct Phone

Practice Information

Practice Name

Office Email

Office Phone

Office Website

Street Address

City

State

Zip Code

Step 5 of 14

Practice Structure

Tell us about your team.

We need to understand the size and structure of your practice.

# of Doctors

Your Role

# of Admin Staff

# of Clinical Staff

Step 6 of 14

Financial Data

Practice Numbers

Use actual figures from your end-of-year reports. Overhead is calculated before doctor compensation.

Annual Collections

Last Year ($)

Two Years Ago ($)

Three Years Ago ($)

Overhead % (Before Doctor Pay)

Last Year (%)

Two Years Ago (%)

Three Years Ago (%)

Fee Schedule — All-In Pricing ($)

Molar

Anterior Re-tx

Pre-molar Re-tx

Molar Re-tx

Emergency Appointment Fee ($) Additional fee charged for emergency slots — enter 0 if none

Cost Data

Last Year's Annual Staff Costs ($)

Last Year's Annual Direct Costs ($)

Step 7 of 14

Insurance Data

Insurance networks & write-offs.

List each insurance company you are contracted with and their approximate share of collections.

Insurance Contracts

Insurance Company Name

% of Collections

Last Year's Annual Insurance Write-offs ($)

Step 8 of 14

Scheduling

Your schedule & hours.

Help us understand how your clinical week is structured.

Weeks Worked / Year

Days / Week

Treatment Spots / Week

What Time Do You Open?

What Time Do You Close?

Lunch Break?

Lunch Duration (minutes)

Step 9 of 14

Treatment Data

Treatment mix breakdown.

Enter your approximate treatment mix percentages for last year. All fields are required.

Treatment Mix — % of Total

Anterior (%)

Pre-molar (%)

Molar (%)

Ant. Re-tx (%)

Pre-mol. Re-tx (%)

Molar Re-tx (%)

Step 10 of 14

Operational Metrics

Production & efficiency data.

Use last year's actual numbers where possible.

Efficiency Ratio

Last Year's Efficiency Ratio (%) Total treatments ÷ available spots

Completed Treatments

Last Year

Two Years Ago

Three Years Ago

Technology Select all that apply

Microscope CBCT GentleWave Laser

Scheduling

How Far Out Are You Typically Booked?

Visit Distribution (%)

Single Visit (%)

Two Visit (%)

3+ Visit (%)

Accounts Receivable

Current AR Balance ($)

Typical AR Balance ($)

Step 11 of 14

Referral Network

Your referral base.

Understanding your referral network is a key component of the assessment.

Core Referral Reach Radius (miles)

Top Referring Dentists (20+ cases last year)

First Name

Last Name

# Cases

Other Cities You Draw Significantly From Separate multiple cities with commas

What Do You Enjoy Most About Your Referral Base?

What Do You Enjoy Least About Your Referral Base?

Clinical Add-Ons

Do you place permanent restorations after treatment?

Do you place posts?

Which CDT fee codes do you typically charge in total for a molar treatment? Separate codes with commas

Step 12 of 14

Practice Reflection

What matters most to you.

These answers help Dr. Carruth understand where you're coming from before you ever speak.

What Do You Enjoy Most About Your Practice?

What Do You Enjoy Least About Your Practice?

What Would You Not Want to Practice Endodontics Without?

Step 13 of 14

Goals & Mindset

Where you're headed.

Be direct. These answers shape the entire assessment conversation.

Do you feel you currently have a business operations strategy?

What do you currently desire most professionally?

What do you currently desire most personally?

Readiness Assessment

How willing are you to make changes?

How willing are you to implement changes quickly?

How eager are you to get started?

Step 14 of 14

Almost There

A few final details.

Last step before checkout. After checkout is complete, your assessment will be completed in approximately 3-4 weeks after which you will be contacted to schedule your video call with Dr. Carruth.

What is your favorite local special occasion restaurant?

T-Shirt / Jacket Size

What influenced you most to work with us?

Payment & Scheduling

Your practice assessment is $9,000.

Clicking below will submit your completed application and take you to the secure checkout page.

By purchasing, you agree to our Terms & Conditions, Privacy Policy and Refund & Cancellation Policy.

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