Henry Schein Revenue Analysis Agreement & Intake Form

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Practice Name:
Owner / Lead Dentist Name

First NameLast Name
Street Address
Street Address 2
City
State
Zip Code
Best Email
Best Phone Number

Please select all licensed specialty types rendered at your practice location(s):
Henry Schein Field Sales Consultant Name

First NameLast Name
What is your Henry Schein Account Number?
Thrive Signature Customer?

What type of practice are you?
What percentage of your patients would you estimate are covered by PPO Insurance? (Most Practice's are 70%+)
Annual Insurance Collections (approx.)
What is your current A/R over 90 days?
Number of Active Patients
What percentage of patients are in Perio Maintenance?
Enter 0 if none
Number of Providers
Number of Hygienists
Indicate Which Days You Are Open Per Week
Number of Days Per Week
Select the Practice Management Software you use:
>> Click here to view Production Summary Export Instructions
Upload Production Report (12 Months)

Upload
.csv is preferred, .pdf or .xlsx is accepted Cancelof
Upload Current Fee Schedule (UCR)

Upload
.csv is preferred, .pdf or .xlsx is accepted Cancelof
>> Click here to view Insurance Collections report export instructions
Upload Insurance Collections Report (Last 12 Months)

Upload
.csv is preferred, .pdf or .xlsx is accepted Cancelof
I confirm this Production Summary contains production for the past 12 months and is categorized by individual codes, and is legible and not handwritten.
I confirm my details are accurate and authorize Henry Schein to bill the Henry Schein Revenue Analysis fee to my account.
By completing this form, you (1) agree to purchase a Henry Schein Fee Revenue Analysis and to be billed the one time cost of $499; (2) agree to such purchase electronically; and (3) accept and agree to Terms and Conditions relating to Henry Schein, Inc., available here. Please read the terms and conditions before purchasing the Henry Schein Revenue Analysis.
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