Practice Data Questionnaire

Name*

First Last

Home Address*

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

Home Phone

Cell Phone

Private Email*

Which optometry school did you attend?*

When did you graduate from optometry school?*

What are your top three strengths?*

What are your top three weaknesses?*

What are your expectations of the consulting program?*

List all the doctors in your practice

Doctors

One per line. Please include full name, optometry school attended, level (partner, associate, etc.), and number of years working together.

Practice Information

Practice Name*

Practice Address*

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

Practice Phone Number

Practice Website

Practice Facebook

Type of Software*

Paper or EHR?

Are you satisfied with your software?*

Are you hoping to evaluate other software systems in the next 12 months?*

Are you or will you be participating to qualify for the Merit-based Incentive Payment System?*

How many years have you practiced in this community?*

How many years have you practiced in this location?*

What type of office setting do you occupy?*

If other, please specify:

How many square feet do you occupy?*

Do you own this building?*

Office Hours

Please define the exact hours for your primary office.

Monday*

(open-close)

Monday*

(open-close)

Tuesday*

(open-close)

Wednesday*

(open-close)

Thursday*

(open-close)

Friday*

(open-close)

Saturday*

(open-close)

Sunday*

(open-close)

List clinic hours worked by doctor:

Total doctor hours per week:*

Total clinic hours per week:*

Do you have multiple practices?*

Satellite Practice Information

If applicable, please complete the information below for your Satellite practice(s):

Satellite Practice Name*

Satellite Practice Address*

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

Satellite Practice Phone

How many years have you practiced in this community?*

How many years have you practiced in this location?*

What type of office setting do you occupy?*

If other, please specify:

How many square feet do you occupy?

Do you own this building?*

Satellite Office Hours

Please define the exact hours for your primary office.

Monday*

(open-close)

Tuesday*

(open-close)

Wednesday*

(open-close)

Thursday*

(open-close)

Friday*

(open-close)

Saturday*

(open-close)

Sunday*

(open-close)

List clinic hours worked by doctor:

Total doctor hours per week:*

Total clinic hours per week:*

Business Management Background

What is your financial management software or system?*

Are you interested in learning about wgfinancial, Williams Group’s accounting and payroll services?*

What was the practice's cash receipts and net income (including all doctor’s compensation and benefits) for the last three years?

2017 Cash Receipts

2017 Net Income

2016 Cash Receipts

2016 Net Income

2015 Cash Receipts

2015 Net Income

What do you anticipate the practice's cash receipts to be next year?*

As you experience practice growth, does net income increase proportionately to cash receipts?*

What is your cost of goods sold percentage?

Frames

Contact Lenses

Ophthalmic Lenses

Other

What is your staff salary expense percentage (excluding all doctors compensation)?*

Do you keep an updated inventory record?*

What is your average monthly inventory?*

Please list employee information

Employees

One per line. Please include full name, wage/salary and hire date.

What are the total staff hours per week?

Are you part of a buying group?*

If yes, please list:

Do you keep monthly profit and loss statements?*

Do you keep year-end financial information?*

How often do you review your A/R report?*

If yes, please list

Current - Third Party

Current - Private Pay

Current - Total

30 Day Accounts Receivable - Third Party

30 Day Accounts Receivable - Private Pay

30 Day Accounts Receivable - Total

60 Day Accounts Receivable - Third Party

60 Day Accounts Receivable - Private Pay

60 Day Accounts Receivable - Total

90 Day Accounts Receivable - Third Party

90 Day Accounts Receivable - Private Pay

90 Day Accounts Receivable - Total

120 Day Accounts Receivable - Third Party

120 Day Accounts Receivable - Private Pay

120 Day Accounts Receivable - Total

Grand Total - Third Party

Grand Total - Private Pay

Grand Total - Total

Have you accumulated practice cash reserves?*

Are you currently utilizing a budget to control your practice expenses? If so, what are you using?

What insurance plans are you currently a provider for?

At your Primary Office:

What percentage of your patient base is third party care (if applicable)?

What percentage of your patient base represents Medicare (if applicable)?

What percentage of your patient base represents Medicaid (if applicable)?

What percentage of your patient base represents Vision Service Plan (VSP) (if applicable)?

At your Satellite Office:

What percentage of your patient base is third party care (if applicable)?

What percentage of your patient base represents Medicare (if applicable)?

What percentage of your patient base represents Medicaid (if applicable)?

What percentage of your patient base represents Vision Service Plan (VSP) (if applicable)?

If applicable, please list additional satellite location information.

Professional fee for new patient contact lens evaluation?

Tier 1:

Tier 2:

Tier 3:

Tier 4:

Tier 5:

Professional fee for established contact lens evaluation?

Tier 1:

Tier 2:

Tier 3:

Tier 4:

Tier 5:

Do you establish monthly projections and goals?*

Do you monitor the monthly sales on a weekly basis?*

Do you monitor the monthly receipts on a weekly basis?*

Do you monitor the monthly per-patient receipts on a weekly basis?*

Do you monitor the weekly shopper calls on a weekly basis?*

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List all the doctors in your practice

Practice Information

Office Hours

Satellite Practice Information

Satellite Office Hours

Business Management Background

What was the practice's cash receipts and net income (including all doctor’s compensation and benefits) for the last three years?

What is your cost of goods sold percentage?

Please list employee information

If yes, please list

At your Primary Office:

At your Satellite Office:

Professional fee for new patient contact lens evaluation?

Professional fee for established contact lens evaluation?

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