Medical Office Design Questionnaire

Contact Information*

First/Last Name*

Office Phone

Mobile Phone*

Your Email*

Billing Address

Existing Practice Information

If you do not have an existing practice however you maybe working as an associate please provide information that can help us realize your existing work conditions which you may like or dislike where we can enhance and or incorporate things that works for you.

Existing Practice Name

Existing Practice Address

Are you leasing at the present time? YesNo

Can you continue leasing month-to-month should you need it? YesNo

Existing Square Footage

Do you have an equipment specialist that you work with? YesNo

If yes, with which company?

Equipment Specialist Name

Equipment Specialist Email

Equipment Specialist Phone

Do you work with a certified consultant? YesNo

If yes, what company?

Certified Consultant Name

Certified Consultant Email

Certified Consultant Phone

Presently, which certification do you have? Please be specific.

Do you presently work with any financial institution? to acquire funds for your project? YesNo

Which institution

Do you need any referral to be connected to a financial institution? YesNo

Do you have a legal counsel reviewing your purchase or lease agreement? YesNo

Do you need any referral to be connected to a legal counsel? YesNo

How do you manage your medical billing?

Which management software or company do you use?

Are you planning to bring any existing medical equipment to your new office? YesNo

If yes, which items?

Are you planning to bring any existing furniture to your new office? YesNo

If yes, which items?

How do you manage your brand and digital marketing?

Do you intend to create a new brand? YesNo

Logo YesNo

Website YesNo

Practice Name YesNo

Future Practice Project Information

Is this project confidential? YesNo

Project Address

Is this your first practice "startup"? YesNo

What is your specialty?

Is there any other specialty included in this new project? YesNo

If yes, what specialties?

What services do you intend to provide in this practice? Please provide a brief description of overall practice.

Are you presently an associate provider working with an organization? YesNo

If yes, how many years have you been practicing

Are you moving your practice to a new location? YesNo

Are you moving to have a larger practice? YesNo

Have you realized the deficiencies and shortcomings of your existing practice or the organization you work at? YesNo

Surgery Suite (if applicable)

Number of operating rooms (O.R.) required?

Describe how you see your operating room functioning:

How many surgeons/providers do you envision having at your surgery center?

Number of team members?

Do you need any procedure rooms? YesNo

Titles for each team member(s)? Please identify as best you can.

Do you need TV's at ceiling? YesNo

Do you need TV? YesNo

Please describe location for TV (ie: On one wall, at foot or head of the patient; at both walls at patient sides?)

Which side do you need the cabinets (ie: Head of patient, foot of patient, side of patient)

What kind of procedures/surgery do you plan to do at any given time now and in the future?

Do you like medical gases to be plumbed to your O.R.? YesNo

Do you need to reach medical gases from the ceiling? YesNo

Do you need portable medical gases? YesNo

Do you need UPS (Uninterupted Power Supply)? YesNo

Do you prefer a generator? YesNo

What certifications do you plan to have for your surgery center?
AAASFAAAHCJoint CommissionNo certification requiredOther

If other, please list here.

Sterilization

Operations and Delivery of Care

Is your vision regarding your existing practice changing, and is this the reason you are looking to open a new practice or a much larger practice? Please explain.

Does your office have a good flow?
YesNo

Please explain

Have you examined the operations within your office, how efficient you are? Please explain.

What would you change about the flow within your existing practice, so that you may enhance operation?

Does your staff produce with high efficiency and do they meet your expectation?
YesNo

How do you manage efficiency in your office? Please explain.

Does your patient stay in the waiting room more than 10 minutes prior to being seated at the dental chair?
YesNo

Do you have laser equipment, and if not, do you think laser technology will help attract more patients?

How many assistants do you have presently?

How many hygiene bays do you have?

How many operator spaces are dedicated to hygiene?

Would additional rooms or bays dedicated to hygiene produce more revenue to your practice?

Are you losing production due to lack of operatory space? Please explain.

Do you have enough operatory? Please explain.

Have you examined or consulted with an architect regarding operation of your future office and how efficient that might become? Please explain.

Have you examined how the future of dentists and dentistry would be impacted by your new physical environment?

Have you examined if next generation of dentists will be attracted to your office due to state-of-the-art technology, equipment, physical environment, or any other aspect that makes you stand out above others? Please explain.

How are you planning to increase your productivity and revenue? Please explain in detail.

How are you planning to enhance your operations? Please explain in detail.

How are you planning to enhance your staff productivity? Please explain in detail.

State of Mind

What is it that you do not like about your existing practice? Please be specific and itemize each and everything you do not like.

What are the things that you like about your existing practice? Please be specific and itemize each and everything you like.

What are the things that you love about your existing practice? Please be specific and itemize each and everything you love.

What are the things you would like to keep as is? Please be specific.

Please describe your feelings about your practice in six words. Please note this is about how you feel when working your practice everyday; i.e. depressing, cluttered, dark, phobic, awesome...

Does your team "can't wait" to get out of the office right at 5:00pm?
YesNo

Please explain why.

What can you do to keep your team longer at the office?

Have you ever thought about what to do to enhance your team's state of mind and if so what are your thoughts?

Have you ever thought about what to do to enhance patient experience and if so what does that entail?

Why have you not done anything about it until now? Please explain.

What are the limitations that have stopped you from doing this?

What are the risks that have stopped you from doing this?

What do you think the benefits are if you move forward and take the risk?

Vision

What is your vision for your new practice?

How do you see yourself in this practice in the next 10 to 15 years?

Will you have associates or partners in this practice within the next 10 to 15 years?
YesNo

How many days do you foresee yourself working now and within the next 10 to 15 years?

Are you planning to sell the practice and its patients in the future?
YesNo

Are you planning to sell the real estate (if you own it) or keep the real estate and collect rent but the sell practice?
YesNo

Has your vision changed from what presently you are practicing or is this vision been with you all along and it's now time to implement it? Please explain.

How do you see your practice evolving in the future?

Will you be adding additional services to the practice, if so what are they? Please explain.

Is this a multidisciplinary practice or one speciality or general practice? Explain your vision of the type of care you will be providing in the future.

Are you planning to have additional practices in the future?
YesNo

Are you aiming at making a brand to multiply your practice?
YesNo

Why are you choosing to purchase or lease this certain sqft that you have in mind? Please explain.

Does this certain sqft relate to your vision? Please explain.

How are you planning to increase revenue in your practice, and is this part of your vision? Please explain.

Why are you opening this new practice?

Do you have an exit strategy in mind? Please explain.

How will you attract the next generation of dental professionals in your practice? Please explain.

How can you be on the top of your game in the next 15 years? Please explain.

Do you consider yourself among dental professionals that want to make a change in the future of dentistry and how are you planning to do it?

Have you examined what future dental millennials are requiring to practice dentistry?

Are you looking for someone to create the following branding items for your business? (check all that apply)
Company logoCompany websiteBusiness cardsFlyersCompany forms

Please describe in detail how you would envision the future physical environment of your new dental office.

Do you think this could help patient experience and staff productivity? Why? Please explain.

Budget

Do you have a realistic budget established for your new practice?
YesNo

If yes, what is your budget and why?

How did you come up with this budget?

Please rate from 1 to 10 (10 being the highest end and 1 being the lowest end): In regards to interior finishes, qualities, and how the end resulted space looks like, what number would you choose?

Based on the number you chose, does that correspond with the type of clientele you intend to attract or is this solely personal?

Do you want the interioror environment to match the type of clientele you care for or does it matter?

Did you know budget is directly related to the cost of finish materials but does not relate to how the space would feel like?
YesNo

Does your budget match your vision?
YesNoI don't know

Have you contacted an architect or general contractor to ask about construction cost and if so what did you hear? Please explain.

Do you know what Design Built vs. Design BID is?
YesNo

Please explain.

Do you know the difference between construct budget and project budget? Please explain.

Timeline

How soon are you planning to move in to your new space? Please provide a date.

Are you leasing at the present time and if so when does your lease end?

Can you continue leasing month to month should you need it?
YesNo

Have you contacted an architect or general contractor to ask about the timeline they require to design and build your office and if so what did you hear?

Have you negotiated your new lease or closing dates if you are purchasing?

Design and Construction Process

Have you discussed the architectural design process and building permit with an architect? YesNo

Do your designers have an architectural license to practice architecture? YesNo

Have you checked the limit of professional liability insurance of your architect? YesNo

If the builder is designing your practice, have you checked to see if they have licensed architects on their payroll or will they be farming out the drawings to an architect you will never meet? Licensed architects on payrollFarmed out architecture

Do the builders employee licensed professionals such as licensed interior designers to work on your project? YesNo

If the builder is designing and building your project, are they introducing you to professionally licensed architects, engineers, and interior designers for you to work with them, or does the builder representative works with you directly?
Direct introductionBuilder representative

Do you think if the builder designs and builds your practice it will be less expensive? If yes, please explain?

Does your builder give you the design for free? YesNo

Do you know the benefit of working with a licensed architect and interior designer over working with non-licensed, individuals? YesNo

Have you been explained the material cost and total project cost with your architect? YesNo

Do you know what is the difference between construction cost and project cost? Please explain.

Do you know what is the role of an architect is during the design process as well as the construction period? Please explain.

Do you know how important it is to work with an architect who is an expert in designing the surgery / medial environment? YesNo

Do you intend to work with a builder who is an expert in building Surgery suites/Medical practices? YesNo

Form Submission

In order for us to clearly understand your present office, and the way you operate, please send us pictures of your existing office. Please also create a Pinterest page, or provide us with photos of the things you like or dislike. The images do not have to be related to a dental office, they can be anything and everything. This process is what we call "getting to know you." The more photos you provide for us, the better. Once we receive this form and pictures, we will then set up a meeting to discuss all details in a 3-hour meeting so that we may then begin to work with you.

Thank you for taking the time to share, we look forward to bringing your dream to reality.

KOHAN medical office design team