EXPLORE OPPORTUNITIES | The LifeGuard Approach

THE LIFEGUARD APPROACH:
EXPLORING LIFE-SAVING OPPORTUNITIES

PRACTICE NAME:

DOCTOR(S) NAMES:

OFFICE ADDRESS:

OFFICE PHONE:

OFFICE EMAIL:

WHO COMPLETED THIS FORM?

WHAT IS THEIR JOB DESCRIPTION?

WHAT IS THEIR EMAIL?

WHAT IS THE STARTING DATE YOU ARE USING?

WHAT IS THE END DATE YOU ARE USING?

NUMBER OF HYGIENISTS:

NUMBER OF AVAILABLE PATIENT HYGIENE HOURS / WEEK:

Admission fee for this course is $10

TOTAL HYGIENE PRODUCTION (using the above dates):

TOTAL OFFICE PRODUCTION (using the above dates):

AVERAGE NEW PATIENTS / MONTH:

D0120:

D0180:

D1110:

D4910:

D4341:

D4342:

Thanks for Submitting Your Information!