PRACTICE QUESTIONNAIRE
CLINIC HOURS

(Please Indicate any break for lunch)

NAMES OF TEAM MEMBERS

Include job title and years of experience

CLINICAL TEAM
Do you also have a Records Tech?
Do you also have a sterilization tech?
Are Staff able to complete appointments in allotted time?
Are all staff able to complete appointments in allotted time?
Are all staff highly skiiled in all procedures?
Do you have a Clinical Coordinator?
Is he/she effective at running clinic, training, etc?
TREATMENT
CLINICAL MANUAL
Do you have a clinical manual?
Does it include photographs of the instruments and set ups?
Does it need updating?
CHARTING
Who Does Charting?
Is this system effective?
Type of treatment cards used?
Is training needed?
Are consistent abbreviations used for charting?
TREATMENT PLANS
Are all treatment plans listed on charts?
Are assistants able to read and follow treatment plans?
Is training needed in this area?
Is archwire sequencing consistent?
Are assistants able to follow and anticipate?
Is training needed?
Are estimated completion dates met?
SET UPS
Type Used
Are setups complete?
TRAY LINERS
Are tray liners used?
If no, do you want to implement tray liner usage?
SUPPLIERS
BANDING/BONDING
Do you do direct or indirect bonding?
If you indirect bond, what is the type of tray?
If occlusion is compromised, what options might you use?
Are you using Invisalign?
If no, are you interested in Invisalign?
If yes, do you wish to improve your technique?
APPLIANCES
ELASTICS
Options used
RETAINERS

Removable:

Hawley
Wrap
Modified Spring
Essix
Imprelon

Fixed:

Bonded Lower 3 - 3
Is all staff trained in delivery of retainers and/or appliances?
Do you have an in house lab?
EMERGENCY APPOINTMENTS
Do you track emergency appointments?
If no, do you want a system in place?
UNIFORMS
Are uniforms provided?
Laundry on site?
Cleaning service?
STERILIZATION
Are you able to keep up with sterilization?
Do you want to change sterilization systems?
VERBAL SKILLS
Are all assistants up to par?
Is all scripting consistent between assistants?
Is scripting in clinical manual?
Is training needed?
Are all assistants able to handle difficult parents/patients?
Do assistants need training in this area?
CHAIRSIDE STORAGE
Is storage consistent between units?
ORDERING
Do you have an effective system in place for ordering?
If no, do you want to establish an ordering system?
Is clinical time given for ordering?
Do you run out of items?
Is supply overflow area well organized?
EXTRA DUTIES
Are extra duties equally delegated between assistants?
Is clinical time given for extra duties?
CONTESTS
EDUCATION PROGRAMS/SCHOOL PROGRAMS
Do you need help in this area?

Thanks for submitting!