Practice Evaluation Form

Dentist Name*

Do you have a separate legal entity set up for a sleep practice?

Yes
No

State*

Your Sleep Practice

How 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?

ARES	WatchPAT 200/300	NoxT3 / STAT DDS	Embletta	ZMachine	Medibyte	Other

Do 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.