StreamDent - New Patient Research Form

Goal: Provide excellent customer service to each and every patient. Thank you for calling Flemingsburg Dental Care, this is _____, how can I make you smile? (Stop, Smile, and Listen!)

Call Taken By: *
Today's Date * / MM / DD YYYY
Patient's Name - Get the name of the caller, and use it frequently. Just ask, May I have your name? If they ask a question, say, "I'd be happy to help you with that, may I have your name please?" ***CHECK NAME IN DENTRIX IMMEDIATELY!*** * First Last
Goes by:
Pronounced

Use this field to type out phonetic spellings for hard-to-pronounce or odd names.
Patient is: *
(If patient is a child) Child's Age:
Person Calling if Other than Prospect

Please record person's name and relationship
Email
Use the name of the caller during the call: Fantastic _____, let me be the first to welcome to Flemingsburg Dental Care. What prompted you to call today?
Reason for Call
Reason for Call - Other
Reason for Call - Coupon Offer
Status New Patient Active Patient Reactivated Patient
Repeat the problem back to the patient. (Problem, Agitate, Solution.) "Okay, ______. Let me just repeat it back to you to make sure I've got it right." Answer the patient's questions, avoid unnecessary info, don't get complicated.
Emergency Information

Include such items as: Where the tooth is located; How long has it been hurting? Is the pain constant? Is there any swelling? Are they running a fever?
Chief Complaint - "What would you like us to do for you?" Please copy and paste this info into the Dentrix appt note, before clicking submit.

Remember that you can copy and paste from this field into the Dentrix appointment field, just do so before clicking Submit.
Did the patient indicate that they are a "fear" patient? Yes No
Next: Take control of the conversation by asking your own questions: It sounds like you're looking for a great dentist, am I right? How long has it been since you've been to a dentist?
DUAL ALTERNATIVE CLOSE: It sounds like we need to get you in soon, am I right? Guide the patient: Would you prefer to come in (1st ½ day available) or (2nd ½ day available)? Would early or late in the (morning/afternoon) be better for you? Which would be better for you? How would ___ work?
Patient's Scheduled Appointment date: / MM / DD YYYY
Remember, this is NOT today's date, unless they are scheduled today. This is the date they are scheduled for their appointment in the office.
Time : HH MM AM/PM
Is there any insurance we'll be helping you file? If so, put name here.
Employer
Financial Policy Discussion Notes (if needed)

Please list fee estimates given or any pertinent financial policy discussions here.
Fee Quote (if any): $ . Dollars Cents
Get contact info even if they don't schedule. ___, since you're not ready to make an appointment today, I'd like to send you free patient newsletter about… Let me jot down your mailing address and I'll get you last month's issue out to you right away.
Patient's Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - PLEASE TRY TO GET AT LEAST 2 PHONE NUMBERS TO INCREASE DR.'S CHANCE OF MAKING A WELCOME CALL! - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Best time to call - and which number?
How did you hear about us?
Referral Source Details

Please list Friend/Other/Patient/Direct Mail referral source information here.
“I do need to let you know that there is one and only one restriction for your coupon. You must agree to abide by our cancellation policy. If you have to change or cancel your appointment, please give us 48 hours notice so that you can use the offer again.”
DiSC D I S C
Patient's Attitude
Closing: _______, would you like to fill out your forms online before your appointment? Do you know where we are located? What questions do you have for me? Thanks for calling today, _______. I look forward to meeting you and you're going to love Dr. Moorhead. If anything comes up between now and you're appointment, would you please call me at 845-2273 and let me know? We're reserving this time just for you. Dr. Moorhead looks forward to meeting you. Listen for opportunities and share information with the team.

StreamDent - New Patient Research Form

StreamDent - New Patient Research Form

Use the name of the caller during the call: Fantastic _____, let me be the first to welcome to Flemingsburg Dental Care. What prompted you to call today?

Repeat the problem back to the patient. (Problem, Agitate, Solution.) "Okay, ______. Let me just repeat it back to you to make sure I've got it right." Answer the patient's questions, avoid unnecessary info, don't get complicated.

Emergency Information

Next: Take control of the conversation by asking your own questions: It sounds like you're looking for a great dentist, am I right? How long has it been since you've been to a dentist?

DUAL ALTERNATIVE CLOSE: It sounds like we need to get you in soon, am I right? Guide the patient: Would you prefer to come in (1st ½ day available) or (2nd ½ day available)? Would early or late in the (morning/afternoon) be better for you? Which would be better for you? How would ___ work?

Get contact info even if they don't schedule. ___, since you're not ready to make an appointment today, I'd like to send you free patient newsletter about… Let me jot down your mailing address and I'll get you last month's issue out to you right away.

“I do need to let you know that there is one and only one restriction for your coupon. You must agree to abide by our cancellation policy. If you have to change or cancel your appointment, please give us 48 hours notice so that you can use the offer again.”