PRIMUS COMPANIES | Referral Program

Name(Required)

Prefix First Last

Email(Required)

Mobile Phone(Required)

Current Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Desired Date Of Project Completion(Required)

Who Is Your Business Development Contact?(Required)

Who Referred You / How Did You Hear About Us?

Why are you thinking about doing this project?

Where Do You See Yourself/Practice...

IN 5 YEARS

IN 10 YEARS

IN 20 YEARS

What would you estimate the “functional life” of this project to be? That is, how long would you envision staying in the location of the project?

What are your long-term aspirations for your practice? (solo practitioner, associates, more associates, multiple offices, acquire more practices, etc.)

Describe your ideal transition out of this practice and into retirement:

Do you plan to add people to your team in the foreseeable future? Who?

If building new, how many lanes/exam/treatment rooms do you want? If remodeling or doing an addition, how many total lanes/exam/treatment rooms do you want?

Describe the ideal comments your patients would say about you and your office, team, and quality of care.

What are the 5 most important things you want your practice to be known for:

1

2

3

4

5

Are there any niche markets you serve or want to serve? What are they?

What specific things will differentiate your practice from other offices in your area? What will your practice offer that your competitors do not?

Procedures you would like to do more or less of?

Describe your relationship with your practice community in your area.

What five words characterize your personality:

1

2

3

4

5

What are your professional and personal goals that you hope to achieve with your new/updated office?

How would your team describe your management style?

How do you want to be perceived by your patients?

Describe the style of your new office as you see it in your mind:

Do you see value in owning your own building? Why or why not?

How do you want to accommodate potential future growth of the practice?

List in order your top five sources of new patients (i.e., print ads, direct mail, website, referral/ referral program, etc.)

1

2

3

4

5

Do you have a formal marketing program?

How many practitioners will work in this building, including yourself?

Do they each need their own personal office space?

What Hours Of Operation Will The Office Keep?

Number of licensed support staff such as hygienists, vet-techs, opticians, etc.

Number of non-licensed support staff such as receptionists, office-manager, etc.

Your Patients

Current Active Patients

Total Patient Records

Average New Patients/Month

Average Patient Age

How many weeks/months out is the practice currently/typically booked?

Revenue Collections:

YEAR-TO-DATE

LAST YEAR

YEAR BEFORE LAST

DESIRED ANNUAL COLLECTIONS

Revenue Collection Sources:

As a % out of 100

Insurance

Medicaid

Cash

Capitation

Approx. overhead (excluding practitioner salaries):

Ex: 45%

Please enter a number from 0 to 100.

Average % of collections from associate(s) (if applicable) :

Ex: 45%

Please enter a number from 0 to 100.

Average % of collections from merchandise: (lenses, eye-ware, DME, grooming, prescriptions, etc.)

Ex: 45%

Please enter a number from 0 to 100.

Service Areas Of Practice

As a % out of 100

Hygiene

Restorative

Crown & Bridge

Endodontics

Orthodontics

Periodontics

Prosthodontics

Oral Surgery

Other

Service Areas Of Practice

As a % out of 100

Eye Exams

Eyewear

Contact Lenses

Refractive Surgery

Ocular Care

Pediatric Care

Other

Current practice debt, if any:

Approx. business checking acct. balance:

Approximate amount of liquid assets (cash, stocks, cash-value life insurance):

How much capital do you intend to/would you like to inject into the project?

Source of capital injection:

CASH

SBA LOAN

OTHER PRIVATE LOAN

OTHER

Select all that apply

Have you spoken with a lender yet if you plan to use a loan?

What else should we know about you and your desires for your practice?

Primus Companies Referral Program

Revenue Collections: