Practice Assessment Form | Elevate Endo Workshop

First Name

Last Name

Direct Email

Years practicing endodontics

Last year's annual gross revenue

# of insurances in network with

Congratulations! Your practice sounds like it is a great fit for our workshop! To move forward with a practice assessment, 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/date with Dr. Carruth.

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Practice Name

Practice Website

Office Phone

Direct Phone

Untapped fee-for-service referrals opportunity

Annual Fee ≤ local crown fee revenue

Fee ≤ local implant crown fee

Fee ≤ 50% of local implant fee

Full time admin/staff

Part time admin/staff

Total doctors/providers in the practice

If yes, how long is your lunch break? (minutes)

Weeks worked / year

Days worked / week

Treatment spots / week (per doctor)

Consultation spots / week (per doctor)

If you track total spots across all doctors, enter total and set # doctors to 1 for modeling.

Last year's schedule busyness / efficiencyEnter as % (e.g., 85%)

If yes, what is the emergency fee per appt?$ amount

How far out are you typically booked?

Estimated % single visit tx

Estimated % two visit tx

Estimated % 3+ visit tx

1 = Not at all, 3 = Neutral, 5 = Extremely

How much have you budgeted for advisory services ($)?

Core referral reach radius (miles)

Other cities you draw significantly fromComma-separated

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

What is your favorite local special occasion restaurant?

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Financial Inputs

Consultation fee (optional — not used in calculations)

Anterior all-in fee

Premolar all-in fee

Molar all-in fee

Anterior re-tx all-in fee

Premolar re-tx all-in fee

Molar re-tx all-in fee

Two years ago annual gross revenue

Three years ago annual gross revenue

Last year's total overhead % (before doctor pay)

Two years ago overhead % (before doctor pay)

Three years ago overhead % (before doctor pay)

Last year's # of completed treatments

Two years ago # of completed treatments

Three years ago # of completed treatments

Staff costs ($, annual)

Direct costs ($, annual)

Total gross insurance write-offs ($)

What % of your gross revenue is related to each networkEnter details in the Insurance Mix tab (recommended).

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Goals & Context (Optional / Qualitative)

What do you want personally?

What do you want professionally?

What do you want from this experience?

How much have you already tried to improve profitability?

What do you feel is keeping you from where you want to go?

Upload printable high-resolution logo image (link/file name)

Store the file in Drive; paste share link or file name here.

List of additional doctors (partner/associate)

Enter details in the Additional Doctors tab (recommended).

What days do you work and what time do you currently start and end each day?

Enter details in the Schedule tab (recommended).

How often do you stay later than your scheduled hours?

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Congratulations, your practice sounds like it is a great fit for our workshop!

Congratulations, your practice sounds like it is a great fit for our workshop! To move forward with a practice assessment, 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/date with Dr. Carruth.

Oops! Something went wrong while submitting the form.