Practice Statistics

Who Are You Submitting Stats For?

Practice Name*

Primary Doctor Name*

Statistics

How Many Months Are You Submitting Stats For?*

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 2

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 3

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 4

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 5

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 6

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts**

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 7

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 8

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 9

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 10

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 11

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Statistics 12

Month*

Year*

Total Production*

Gross or Adjusted?*

Total Collection*

Total New Patients*

Total Hygiene Appointments (U.S. Codes: D1110, D1120, or D4910) (Canadian Codes: 11111, 11112, 11113, 11114, 11115, or 11116)*

Please Enter Only the Necessary Hygiene Appointments—Adult Prophy, Child Prophy & Emergency/Limited Exams:

Total Monthly Hygiene Appts Available*

Total Prime-Time Hygiene Appts***

Total Days Worked*

**Appts before 8am, after 5:30pm & weekends.

Practice Information Currently on File – Please Verify

Number of Doctors

Number of Operatories

Number of Hygienists

Office Contact to Schedule Meetings

Phone

Daily Hours of Operation – Please Verify

Day 1

Open

Day 2

Open

Day 3

Open

Day 4

Open

Day 5

Open

Day 6

Open

Day 7

Open

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Comments

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