In-Office Dental Sleep Medicine Training

Practice Name*

Practice Address*

Doctor Name(s)*

Your Name* (if different than above)

Your Role*

—Please choose an option—Owner DentistAssociate DentistOffice ManagerRDHRDAOffice Admin

Best Number to contact*

Email Address*

Are you currently offering sleep appliances in the practice?*

YesNo

If Yes, approximately how many appliances are you delivering per month?

We are most interested in learning about:
Rank each statement below from 1-7 (1 = Least Interested, 7 = Most Interested)

◆ How to identify and talk to patients in our practice*

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◆ Building a physician referral network*

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◆ Clinical process: How to get a patient diagnosed easily from your own office*

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◆ Clinical process: How to take proper records for an appliance WITHOUT simply guessing position*

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◆ Clinical process: How to get patients to progressively take ownership of their condition & maximize case acceptance*

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◆ Billing and getting paid by medical insurance*

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◆ WE NEED EVERYTHING – HELP US!*

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Can you commit to at least 6 hours of training time for the whole office?*

YesNo

Any questions or comments?