Planning and Solutions Survey
Please fill out the following Planning and Solutions Survey: The Purpose of this survey is to understand your needs, likes and interests to develop a turn-key office and will help us streamline the process for setting up your dream practice.
Company Name
Contact Name
Your name is required.
Phone
Mobile Phone
Email
E-mail Address is Invalid
The Dream
Have you found the location for your dream practice?
Yes
No
Answer Required
Do you currently have a business plan?
Yes
No
Answer Required
Do you currently have a budget/costs associated in opening your practice?
Yes
No
Answer Required
Do you know what kind of practice modality? (Medical or Optical)
Yes
No
Answer Required
Do you know what type of equipment you want in your office?
Yes
No
Answer Required
Do you know which insurances you are going to take?
Yes
No
Answer Required
The Vision
Do you have a mission statement?
Yes
No
Answer Required
Do you know the philosophy of how you want to conduct business?
Yes
No
Answer Required
Do you know what your core beliefs and values will be for your office?
Yes
No
Answer Required
Do you have an operations manual and an employee manual?
Yes
No
Answer Required
Do you have a training program for employees?
Yes
No
Answer Required
The Image
Do you have a logo for your office?
Yes
No
Answer Required
Do you have a website?
Yes
No
Answer Required
Do you plan on doing any print media or mailings?
Yes
No
Answer Required
Do you have a game plan for community footprints?
Yes
No
Answer Required
Do you have a recall system?
Yes
No
Answer Required
The Strategy
Do you know what benchmarks to follow?
Yes
No
Answer Required
Do you know how to conduct a monthly staff meeting?
Yes
No
Answer Required
Do you know how to ensure your vision/operations are being followed
Yes
No
Answer Required
Do you know how to market your practice?
Yes
No
Answer Required
Do you currently have Electronic Medical Records?
Yes
No
Answer Required
If yes, what system do you currently use?
Will you need help with IT services or IT set-up for your office?
Yes
No
Answer Required
Do you know what kind of equipment and any brands you want to use in your office?
Solutions
Estimated date of completion for this project?
What is your proposed budget for your displays and furniture?
Total Square Feet of the location:
Total number of Doctors:
Total number of Opticians:
Total number of employees:
Will the project be located in:
Select
Strip center
Mall
Free-standing
Medical complex
Answer Required
What floor will the project be located on?
Is your project:
Select
First Office
Renovation
Relocation
Second Location
Expansion
Answer Required
Architect
Have you found an architect for your project?
Yes
No
Answer Required
If yes, what is the name of your architect?
What is his/her phone number?
What is his/her email?
Contractor
Have you found a contractor for your project?
Yes
No
Answer Required
If yes, what is the name of your contractor?
What is his/her phone number?
What is his/her email?
Waiting Area
How many people do you wish to accommodate?
Do you require a Children’s Play Area?
Yes
No
Answer Required
Patient Restroom:
Select
Male/Female
Unisex
Answer Required
Refreshment Area?
Yes
No
Answer Required
Reception/Business Area
Front Desk: How many workstations needed?
Do you want a separate area for check-out?
Yes
No
Answer Required
How many check-out stations needed?
Do you require a File Storage/Archive Storage Room?
Yes
No
Answer Required
How many business offices needed?
Any private offices needed for staff members?
Yes
No
Answer Required
If yes, how many and what are their functions?
Optical Dispensary
How many total frames do you want to display?
Describe your target clientele:
Select
Professional
Family
Children
Upper
Middle
Budget
Answer Required
How many dispensing stations do you require?
Do you require a computer at each of the dispensing tables?
Yes
No
Answer Required
Do you require a dedicated Children’s Display Area?
Yes
No
Answer Required
If yes how many frames?
Do you require an Optical Laboratory?
Yes
No
Answer Required
If yes will you require surfacing or non-surfacing?
Do you require a separate Delivery/Adjustment area?
Yes
No
Answer Required
If yes how many?
What is your style preference?
Select
Traditional
Contemporary
Transitional
Answer Required
Contact Lens
How many training stations do you require?
How do you want the Contact Lens area?
Select
Semi-enclosed
Enclosed
Answer Required
Do you want a sink in the contact lens area?
Yes
No
Answer Required
Pre-Test/Special Testing
How many Pre-Test Rooms do you require?
How do you want the pre-test?
Select
Visible
Private
Answer Required
What instruments do you want to include in the Pre-Test area?
Do you require a separate Visual Field Room?
Yes
No
Answer Required
Do you want HRT/OCT in same room?
Yes
No
Answer Required
Do you want a separate special testing room for Photography?
Yes
No
Answer Required
Do you want Photography in Pre-Test room?
Yes
No
Answer Required
Exam Lanes
How many exam lanes are needed?
When facing the patient chair, which side do you want to stand on?
Select
Right
Left
Answer Required
Do you want a sink in each of the exam lanes?
Yes
No
Answer Required
If no sinks in exam lanes, do you want a central hand washing station?
Yes
No
Answer Required
Ancillary Stations
Do you want a nurse/tech station?
Yes
No
Answer Required
Do you want a Dilation/Holding Area?
Yes
No
Answer Required
How many seats?
Do you want a Patient Education/Consultation Area?
Yes
No
Answer Required
Would you want a combined Dilation/Patient Education Area?
Yes
No
Answer Required
Do you want a storage/utility room?
Yes
No
Answer Required
Do you want a separate computer server room?
Yes
No
Answer Required
Do you need a mechanical room?
Yes
No
Answer Required
Computer Requirements
How many computers do you need in the designated areas?
Waiting
Check In
Check Out
Optical
Lab
Exams
Contact Lens
Special Testing
Nurse/Tech Station
Doctor and Staff Requirements
How many private Doctor’s offices are required?
Does the doctor’s office require a private lavatory?
Yes
No
Answer Required
If so, will the lavatory have a shower?
Yes
No
Answer Required
Do you want a private staff lavatory?
Yes
No
Answer Required
Do you want a conference room?
Yes
No
Answer Required
Do you want a staff lounge?
Yes
No
Answer Required
Will the lounge also function as a conference room?
Yes
No
Answer Required
Additional Notes/Information
Once you are complete click the Submit button.
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