Contact information

Manager: Jadell , Zach

Email: jadell.r@admpcmail.com , zachary@admpcmail.com

Coordinator:

Email:

Office hours:

Monday -

Tuesday -

Wednesday -

Thursday -

Friday -

Saturday -

Doctors:

(Dr. name) (Male or female)( NPI #) (Language they speak) Please also add next to it if they are a(General DR, OS, Pedo or Ortho)

Children:

May be seen from the ages of?

For each Dr and specialty

Whitening:

Do you do whitening, if so what kind along with the price?

Cash Patient:

Limited Exam( No Cleaning) $

Exam Cleaning & X rays $

Recall - $

Exam Cleaning( No X rays) $

Please add the cost?

Cancellation Fee

Within 24 hours?

Within 48 hours?

Please also fill in the cost

Family members per day:

How many family members can we schedule in 1 day?

Scheduling Notes:

Anything important you would like us to know?

Doctor Preferences:

Dr ? Below is an example , please add yours?

First Column:

Crown Prep PFM or All porcelain tooth # (4 units)

Rct # (4 units)

Bridge Prep PFM or All Porcelain #’s (4 Units)

She doesn't do extractions (Unless Dr says other wise )

Second Column:

Sealants ( 2 Units)

Emergency "reason and area" (2 units)

NP (2 units)

Recall (2 units)

Crown del (2 units)

Consultation (2 units)

Third Column:

Fillings Only EFDA is in

Comp fills 1-2 (2-3 Units)

Comp fills 3-4 (4 units)

Hyg Preferences:

If you have one?

First Column and Second Column:

Recalls - 3 units

New Patients - 3 units

Insurances Not Accepted:

Please fill out

Insurances Accepted:

Please fill out

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