TAYLORS
Publix Shopping Center 2801
Wade Hampton Blvd.
Taylors, SC 26897
864-606-0650
Manager: Jadell , Zach
Email: jadell.r@admpcmail.com , zachary@admpcmail.com
Coordinator:
Email:
Monday -
Tuesday -
Wednesday -
Thursday -
Friday -
Saturday -
(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)
May be seen from the ages of?
For each Dr and specialty
Do you do whitening, if so what kind along with the price?
Limited Exam( No Cleaning) $
Exam Cleaning & X rays $
Recall - $
Exam Cleaning( No X rays) $
Please add the cost?
Within 24 hours?
Within 48 hours?
Please also fill in the cost
How many family members can we schedule in 1 day?
Anything important you would like us to know?
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)
If you have one?
First Column and Second Column:
Recalls - 3 units
New Patients - 3 units
Please fill out
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