Please complete application form below

Your name *

Office name *

Are you the decision maker? *

Yes

No

Email *

Best phone number *

Do you have 1 PT or FT hygienist? *

Yes

No

What is your Gross Production YTD? *

Less than $500,000

$501,000-$899,00

$900,000 or More

Where do you want this production to be in 12 months? *

Are you open to learning new ways to accomplish your goals? *

Yes

No

Are you open to paying for coaching if you have at least $10K net increase in production over the next 45 days? (NOTE: It will take at least 30 - 45 days to see a change due to patients who will schedule an appointment and show up for their appointment) *

Yes

No

Do you use Dentrix, Eaglesoft or Open Dental? *

Yes

No

I agree to the terms & conditions provided by the company. By providing my phone number and email, I agree to receive text messages, phone calls, and emails from the business.