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Contact info

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Name *

First

Last

Home Phone Number *

Cell Phone Number *

Personal Email *

Office Email *

Education

Undergraduate training / Year graduated *

Graduate training / Year graduated *

Post graduate training / Year graduated *

Implant training / Year *

Family info

Name of spouse & children *

Social Media

Professional Facebook Username *

Personal Facebook Username *

Instagram Username *

Twitter Username *

LinkedIn *

Other interest / business

Recreational Hobbies / Activities *

Business Interest other than Dentistry *

Practice information

Name of practice *

Address *

City/St *

Office phone *

Website *

Office admin/ yrs of employment *

Clinical assistant / yrs of employment *

Office creed / vision *

What improvements would you want to complete in your facility? *

What challenges in your Practice would you like to resolve in 2019? *

What is the cost of not addressing your Practice challenges in 2019 *

Goals and Vision (Targeting your destiny)

Today's date *

Projected date of death *

Age of death *

Professional goal at time of death *

Financial goal at time of death *

Spiritual goal at time of death *

Health goal at time of death *

Family goal at time of death *

Community goal at time of death *

Legacy goal at time of death *

10 Year professional goal *

10 Year financial goal *

10 Year spiritual goal *

10 Year health goal *

10 Year family goal *

10 Year community goal *

10 Year legacy goal *

5 Year professional goal *

5 Year financial goal *

5 Year spiritual goal *

5 Year health goal *

5 Year family goal *

5 Year community goal *

5 Year legacy goal *

1 Year professional goal *

1 Year financial goal *

1 Year spiritual goal *

1 Year health goal *

1 Year family goal *

1 Year community goal *

1 Year legacy goal *

Next action for professional *

Next action for financial *

Next action for spiritual *

Next action for health *

Next action for family *

Next action for community *

Next action for legacy *

Primary goal that would justify investments in 2019 ADIS *

Visionary goal for 2019 that you feel can't take place with present realities. *

Abbreviated biography *

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