Practice Evaluation Form Submit Your Practice Practice Evaluation Form Dentist Name* Dentist Email** Dentist Cell Phone**Practice Name** Do you have a separate legal entity set up for a sleep practice? Yes No If Yes, the sleep practice name?* Practice Address** Practice City** State*Practice State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther (Canada)Other (International)Practice Zip Code** Practice Phone**Practice Website** Sleep Practice Website (If different) How long have you been in practice? What is your target year of retirement? Your Sleep PracticeHow many sleep patients are you currently treating per month?* 0 (Looking to work with APZME to start) 1-5 (beginner) 6-15 (intermediate) 16-30 (Experienced) 31-60 (Advanced) 60+ (Its all I do) Approximate current sleep practice annual revenue? Is your intent to transition away from general dentistry to full-time sleep?* Yes No If yes, what is your target month/year for this transition? What is your target number of sleep appliances per month?*Do you have a dedicate operatory for sleep?* Yes No Do you have a trained Sleep Care Coordinator / Sleep Ambassador?* Yes No Is your SCC able to focus full time on sleep and not mix in with dental business?* Yes No What are the top 3 appliances you’ve been using? Do you have an Eccovision Pharyngometer/Rhinometer?* Yes No Do you have a CBCT?* Yes No Do you have a digital scanner?* Yes No If yes, which one? Do you have home sleep test devices?* Yes No If yes, how many (Enter #) of which type?ARESWatchPAT 200/300NoxT3 / STAT DDSEmblettaZMachineMedibyteOtherDo you utilize any direct-to-patient HST service?* Yes No If yes, which one? Are you utilizing any disposable single use HST system (watch-pat 100, night owl etc..)?* Yes No Are you registered with Medicare as a DME Supplier?* Yes (Participating) Yes (Non Participating) No Is the registered entity your dental practice or separate sleep business? Are you registered with Medicare Part B? Yes No Are you in-network with any private medical insurances? Yes No If yes, which one(s)? Are you utilizing a 3rd party service for medical billing currently? Yes No If yes, which one(s)? Are you currently marketing your sleep practice services? Yes No If yes, are you using a 3rd party marketing company (Which one)? What media and methods are being utilized? Check all that apply. SEO Google Adwords Facebook/Instagram Radio TV Direct mail Other What is your monthly marketing budget? Are you doing any active outreach to local referring physicians?* Yes No If yes, please describe?Is there anything else you would like us to know about you, your sleep practice or your goals for the future with dental sleep medicine?Thank you for your interest in working with APZME to help you achieve you personal and professional goals with dental sleep medicine. Your submitted information will be held in confidence and reviewed by APZME principals to determine if and how we can best help take your sleep practice to the next level. <br />
