Office Info Sheet

    Practice Name:

    Associate(s) or Partner(s):

    Office Phone #(s):

    Office Fax #:

    Email Address:

    Doctors Home Phone #:

    Mobile/Beeper #:

    Office Manager:

    Office Manager Home Phone #:

    Receptionist:

    Receptionist Home Phone #:

    Assistant:

    Hygienist:

    Office Hours:

    Monday:

    Tuesday:

    Wednesday:

    Thursday:

    Friday:

    Saturday:

    Lunch:

    Prophy Appointment Time:

    Adult:

    Child:

    New:

    Frequency of Procedure:

    Bwx:

    Fmx/Pano:

    Fluoride:

    Office Equipment:

    Prophy Jet:

    Cavitron:

    Titan:

    Microwave:

    Refrigerator:

    Automatic Developer:

    Panorex:

    Computer Software(Name):

    Digital X-Ray:

    Other Information:

    Name of Liability Insurance Company:

    Does it provide an Umbrella Clause for Temporary Personnel?:

    Additional Comments:

    Verification:

    What is


    View Form as PDFOffices are required to stock disposable gloves and gowns for the temporary staff.As per Contractual Agreement, all communication with the temporary is to be directed through Palmetto Dental. Do not request their phone number or give their names to other Dental Offices.Please give directions to your office. Begin from the nearest interstate highway, if feasible. Make note of other businesses and landmarks. Also, give a description of the building.