Questionnarie

Personal Details

Full Name * Phone No *
Clinic Address * Email Id *

Academic Achievements

Course Name College Name Year of Completion Total Cost If Loan ? Amount
Work Experiences Work Experiences
Describe
Describe
Describe
Describe
How frequently you upgrade your knowledge and how ? Describe
When did you start your private practice ? Describe
How did you get this own clinic investment ? Describe
Did you raise loan for clinic setup ? if so Bank Rate of interest
Did you purchase the clinic from other practitioner ? Describe
Do you have a Retirement plans ? Describe
How do you save money when not in business ? Describe
How do you think you can be a role model for others ? Describe
CONSULATION PAST TRANSITION PRESENT
Consulation Fee
Consultation validity and deliverables
Number of new OPs/month
Time Spent with patienyt during consulation ?
Number of patients converted for treatment ?
Reasons for increases in OPs ?
Reasons for decreases in OPs ?