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CLIENT QUESTIONNAIRE

Personal Information
First name:
      DDS     MD
Last Name:
Mailing Address:
City:
    State: Zip:
Home Phone:
    Cell Phone:
Pager:
     Preferred Contact#
Email Address:
     Best time to reach you:

Tell Us About Yourself
Marital status:
Spouse's name:
Spouse's occupation:
Children/ Ages:
 
Tell us a little about your family:
Hobbies or special interest:
Other information you would like to share:

Professional Information
Certification:  
If board eligible, when (if) will you be taking your boards:
College/undergrad:
Graduated:
Medical School:
Completed:
Internship:
Completed:
Residency:
Completed:
Fellowship location and specialty of training:
Other information you would like to share:

Malpractice History
Have you ever been named in a malpractice suit?
Have you ever had a license suspended or revoked or limited?
Have you ever had your hospital privileges suspended or revoked?
Have you ever been treated for drugs or alcohol abuse?
Have you ever been convicted of a felony?
* If yes to above questions, please explain and attach any documents if needed:
Other information you would like to share:

Current Practice Information
How long have you been in practice:
How much longer do you want to practice:
Is your practice in a rural or metro area (if rural how far to metro):
Why did you choose to practice in your current location:
Community size or service area size:
Other community information:
How many other OMS practices are in the area:
Practice philosophy:
Where do you see your practice in 5 years:
Office hours:
Call Schedule:
What is the square footage in your office:
Is your office computerized:
Do you have or are you thinking about adding digital radiography?
How many OMS are in your practice:
Tell me about your staff, (how many, what positions, how long have they been with you, names):
Do you have a Registered Nurse for recovery:
What is your insurance mix:
Do you see Medicaid patients?
Does your office do financial arrangements for patients that cannot pay?
Have you recently updated or planning to update your office in any way?
Reasons for bringing on another OMS:
Do you anticipate any challenges for the new OMS:
* If yes, what challenges do you anticipate:
If you are replacing an OMS leaving, please explain the reasons for departure:
Other information you would like to share:
Preferred OMS Situation
Employee      Associate      Partnership track (in years)  
Would the ideal be: Board Certified     Board Eligible     Fellowship Trained  
Do you have a preference if the OMS is dual degreed:  
Please list the names of candidates that you are in touch with so we do not contact them:
 
When would you want the OMS to start:
  
Contract Details (Income, Partnership track, Buy in-Buy out, etc.):
  
Are you flexible with the terms of your contract:  
Other information you would like to share:
  

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