Thank you for taking the time to thoroughly complete the Practice Profile Form. The more detailed information that you provide, the more successful we will be in searching for the ideal candidate(s).If you have multiple locations that you are hiring for, we require a separate Practice Profile Form for each location. Practice Company InformationName on dental practice sign at physical address where associate will be working : Name on dental practice* Dentist Owner Name: Dentist Owner Name*
Address of the location the associate will be practicing:
Office Phone Number: Office Phone Number* Website: Website* Would the new associate be the only dentist working in the practice? Yes No*
Hiring Manager Direct Contact PersonName/Title: Name/Title* Office Number: Office Number* Mobile Number: Mobile Number* May we text you? Yes No* Email Address: Email Address*
Practice Background Number of dentists working in hiring practice: Number of dentists working in hiring practice* GP GP* Specialty Specialty* If specialties, please list:
Days and hours of operation for hiring office:
Day and hours to be worked by associate:
Will the associate be working at multiple locations?
If yes, please list the locations by address:
Which days of the week will the associate be working in:
Number of hygienists at hiring location: Number of hygienists at hiring location*Number of daily hygiene exams assigned to associate: Number of daily hygiene exams assigned to associate* Will the associate have autonomy in materials/lab use? Yes No* Mix of Patients: % FFS* % FFS % PPO* % PPO % DMO* % DMO % Medicaid* % Medicaid Practice Management Software: Practice Management Software:* CAD CAM: CAD CAM: * Digital X-Ray System: Digital X-Ray System:* Implant System: Implant System:* Endo system: Endo system:* Pano CBCT* Digital Scanner* Intra-oral Camera*
Position/DetailsWhy are you seeking a candidate(s)? Replace Expansion* Is this search confidential? Yes No* Is this search confidential? Is this search confidential?* Who are you hiring: GP Specialty Pedo GP Practicing Pedo Ortho Endo OMS* Minimum years of contract? Minimum years of contract? * Non-compete? Yes No* Distance and duration of non[compete?
Compensation Package:Will you be offering a signing bonus?
Daily Guarantee, Amount?*Daily Guarantee, Amount?* How long? How long?* % of Production, What is the %?*% of Production, What is the %?* Is it tiered? Yes No* % of Collections, What is the %?* % of Collections, What is the %? * Is it tiered? Yes No* Will associate be paid as: W2 1099*
Is there Partnership/Ownership/Equity Opportunity? Yes No* Uniforms supplied? Yes No* Specific Position Requirements:
Years of experience required: Years of experience required:* Is a new grad acceptable? Yes No* Are you willing to sponsor candidates needing H1B or Visa assistance? Yes No* What other resources are you using for the search? Other Recruiter Internal HR Department Job board (Indeed etc.)*
Ideal/Candidate Please describe your ideal candidate
Please describe the culture of your organization
Please describe any unacceptable candidate qualities/characteristics (Deal[breakers)
Important/Note Please list the candidates that you have interviewed, rejected or that you are in the process of interviewing during the past 12 months:
Important: This information will keep us from spending time recruiting these candidates. Please note that if a candidate is not on this list, he/she cannot be excluded from your Dental Careers contractual obligation and placement fee. Please initial that you understand this statement. Initials Initials* Form Completed by: Name: Name* Title: Title*