avoid cancellations

Dental Office Tips to Reduce Last Minute Cancelations and Broken Appointments
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Dental Office Tips to Reduce Last Minute Cancelations and Broken Appointments

Hello Friends,

Are same-day broken appointments stressing you out? You leave the office at the end of the day with a beautiful, full schedule for the next day and arrive back at the office in the morning only to have the schedules fall apart at the last minute. Ugh! If this ever happens to you I know how frustrating that can be. Not to mention, it kills production.

In this article, you will find several ways to greatly reduce last-minute schedule changes. I am certain that if you follow each step, you will stress less, make more money, help more patients, and have more fun.  Please print it out and share it with everyone on the team. We need everyone in the office to follow the same protocol/system for you to be successful.  Consider reviewing this at your next huddle or team meeting.

Tips and Ideas to reduce last-minute cancellations and no-shows:

Consistently Be Great! – Do everything to ensure that each and every patient has a great experience during their appointments.  Give them something good to talk about and a reason to keep coming back!

STOP moving appts around! A sure-fire way to aggravate patients, cause them to disrespect your time and the schedule, or for them to think you don’t know what you’re doing is by moving their appointment times. Unless, of course, they have asked to be on your Priority List.  Calling patients to come in early, come in late, or come in on a different day is annoying and I promise you it is hurting your schedule and production. I can’t emphasize this enough –  Respect their time and they’ll respect yours.

Appointment Reminder Systems – Ensure that you have an effective interval set up to remind patients of their appointments and that your message is helping not hurting the practice. For example, Don’t say “Calling to confirm” – it should be “We’re looking forward to seeing you on ____ at ____. OR ____ is looking forward to seeing you…” When is the last time you reviewed your electronic appointment reminder messages and intervals and your appointment confirmation protocol?

Unconfirmed Appointments – If it is 1 day before the appointment and you have a patient or patients that haven’t responded to your appointment reminders, you must pick up the phone and call them.  You shouldn’t be able to look at the day’s schedule during your morning huddle and see unconfirmed appts.

Cancels – Using the word cancel or cancellation sends a poor message to your patients. It tells them that cancellations happen and are expected. We don’t want that. You can say ”this doesn’t happen very often but if for some reason you need to change your reservation with ___, we ask that you please provide us with at least 48 hours’ notice.”

Stay on Time – See your patients at their appointment time. This means they should be seated in the treatment chair on or before their appt time. Avoid running behind schedule. Don’t keep them waiting too long in their chair either (ie: waiting for the doctor to come in for the examination).

Appointments ASAP – If a patient calls (especially a New Patient) to schedule an appointment and they can’t get in for 2 or more weeks you are at risk of that patient calling somewhere else to get an appointment sooner or other life’s distractions and priorities getting in their way moving them to cancel last-minute or no-show. If your schedules are so full that patients are having to wait to get in they might feel like you’re too busy for them or that their dental care needs are not important. If you do not have an immediate opening let the patient know that you’ll place them on your priority list and while it doesn’t happen very often if there is an unexpected change to the schedule and you can see them sooner they’ll be the first to know.

Doctors, if you’re struggling to reach your practice goals or that there is too much chaos in your practice– feel free to contact me for a complimentary, no-obligation 30-minute telephone consultation at bhaydenconsulting@gmail.com to see if a coaching relationship is right for you.

New Patients– Don’t rely on electronic reminders for your new patients. Instead, call and let them know you’re looking forward to meeting them and briefly share with them what to expect during their first visit.

Bad Appointment History – If a patient has a history of not showing up or canceling last minute, please don’t schedule any future appointments for them.

Treatment Plans and Financial Arrangements – Every patient that has an appt. scheduled with the doctor for treatment must have a copy of their treatment plan AND a financial agreement before the appt. DON’T ASSUME that the patient is OK with their financial responsibility simply because you gave them a copy of their treatment plan and they didn’t question the cost.  What often happens is they say OK and schedule and then will no-show or cancel at the last minute.

Hygiene Patients – Schedule their next 3, 4, and 6-month appt when they are at the office. Preferably, the hygienist should always schedule the next appointment from the treatment room. Take a second to stress to the patient how important this appointment is and what you’ll be looking for at their next appt. (It’s not just a cleaning and there is a reason for the recommended appt interval.)

Scheduling Appointments – When scheduling appointments for your patients let them know that this time is being reserved exclusively for them. Also, consider having patients pay their co-pay or leave a deposit at the time of scheduling. Especially, if you’re reserving more than an hour on the doctor’s schedule.

VALUE – Walk-Out Statement – Consider itemizing the hygiene appt walk-out statement to include the no-charge services… ie: Oral Cancer Screening, Nutrition Counseling, Oral Hygiene Instructions, Etc. It is so much more than just a cleaning. Be sure to ALWAYS give the full fee for that day even if they have “100 %” coverage with their insurance. They need to hear the actual dollar amount for each visit. Helps to put more value on the appt.

No-Shows / Late Arrivals – Always acknowledge your no-show/late patients with a call 3-5 minutes past their appt. time.  If you get a voice mail – let the patient know you’re concerned because they missed their reservation. Have a system in place for following up on broken appointments. Don’t allow these patients to slip through the cracks.  

Telephone – The dreaded telephone calls for same-day cancellation attempts from your patients. They can destroy a perfect schedule in a matter of minutes. Stay in control of your schedules. Create a system for how to care for and respond to same-day cancellation attempts. Cancellations are not OK. Work together as a team to come up with scripting guidelines that work for your office. Think of all the different scenarios and reasons patients call to cancel (cost, illness, work, no babysitter, schedule conflicts, etc.) and role-play the best responses. Your goal should be, if appropriate, to respectfully help the patient find a way to keep the appointment as scheduled without threatening or embarrassing them.

If you currently leave it up to the patient to call back and reschedule you are not only creating more work for yourself but you’re putting the office at risk of losing that patient due to inactivity. Reschedule/reappoint the patient while you have them on the phone.

Whatever you do and no matter how desperate you are to fill the schedule DO NOT REAPPOINT habitual offenders! You should never be able to look at the schedule and point out who will most likely cancel or no-show. I’m sure that’s never happened in your office, right? 

If you appreciate and enjoy the complimentary ideas and content that I share each month  – I would LOVE for you to PLEASE take a quick minute to leave me a review/recommendation on Google or Facebook. Simply click the following links:    GOOGLE   and/or  FACEBOOK Thank you so much!!

I would love the opportunity to work along with you and your team to help you set and exceed your practice goals. If you would like to schedule a no-obligation, complimentary consultation to learn how our coaching program works, please email me at bhaydenconsulting@gmail.com.

Sending you wishes for a full and productive schedule… one that doesn’t fall apart!

Friends, if you do not know what your office’s broken appointment and reappointment numbers and percentages look like, including how many of your active patients are unscheduled; please take a good look at what those numbers look like and what systems you have in place to track these patients.  You need to know where you’re at currently to know how to best care for your patients and what your potential for growth is. If your practice management software is Dentrix, Eaglesoft, Practice Web, or Open Dental I can help you quickly get that data. Just let me know via email at bhaydenconsulting.com

For additional scheduling tips and ideas visit here: 12 Tips To Help You Fill Holes In Your Dental Schedules with Productive Appointments

Yours for Greater Success,

Betty – Dental Coach

P.S. Please stop by and say hello to me on Facebook, Twitter, Instagram, LinkedIn, and Pinterest

Before you go, would you pretty please do something for me? I would LOVE for you to PLEASE leave me a review/recommendation on Google or Facebook. Simply click the following links:    GOOGLE   and/or  FACEBOOK Thank you so much!!

How to Reduce Same Day Dental Appointment Cancellations and No Shows
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How to Reduce Same Day Dental Appointment Cancellations and No Shows

Hello Friends,

I have been getting many requests for help from dental office team members complaining that their schedules will often fall apart at the last minute. If this ever happens to you I know how frustrating that can be. Not to mention, it kills production.

In this article, you will find several ways to greatly reduce last-minute schedule changes. I can assure you that if you follow each step, you will stress less, make more money, help more patients, and have more fun.  Please print it out and share with everyone on the team. We need everyone following the same protocol/system in order for you to be successful.  Consider reviewing this at your next huddle or team meeting.

Note: If you need a quick-fix for holes in the schedule – check out these ideas: Tips and Ideas to Fill Holes In Dental Hygiene Schedules, However, they are just that, a quick fix. Follow the ideas in this article to prevent them from happening at all.

Dental Office Systems for Reducing Cancellations from Betty Hayden Consulting

Reduce last minute cancellations and no shows by following this protocol/system:

Consistently Be Great! – Do everything to ensure that each and every patient has a great experience during their appointments.  Give them something good to talk about and reason to keep coming back!

STOP moving appts around! A sure-fire way to aggravate patients, cause them to disrespect your time and the schedule, or for them to think you don’t know what you’re doing is by moving their appointment times. Unless, of course, they have asked to be on your Priority List.  Calling patients to come in early, come in late, or come in on a different day is annoying and I promise you it is hurting your schedule and production. I can’t emphasize this enough –  Respect their time and they’ll respect yours.

Appointment Reminder Systems – Ensure that you have an effective interval set up to remind patients of their appointments and that your message is helping not hurting the practice. For example, NEVER say “Calling to confirm” – it should be “We’re looking forward to seeing you on ____ at ____. OR ____ is looking forward to seeing you…”

 Unconfirmed Appointments – If it is 1 day before the appointment and a patient or patients haven’t responded to your appointment reminder system, it is imperative that you pick up the phone and call the patient(s).  You shouldn’t be able to look at the day’s schedule during your morning huddle and see unconfirmed appts.

Cancels – Using the word cancel or cancellation sends a poor message to your patients. It tells them that cancellations happen and are expected. We don’t want that. You can say ”this doesn’t happen very often but if for some reason you need to change your reservation with ___, we ask that you please provide us with at least 48 hours notice.”

Stay on Time – See your patients at their appointment time. Avoid running behind schedule. (Tip: Make sure you are allowing enough time on the schedule for each procedure/appt type.)

New Patients – Every new patient needs a call preferably from the provider 2 days prior to their appt. “Hello, this is ___. I was calling to let you know that I am looking forward to meeting you in person for your reservation on ___ at ___. See you then.”

Please don’t rely on an automated service to welcome your new patients.

Bad History – If a patient has a history of not showing or canceling last minute, please don’t schedule any future appointments for them. However, if you find there are some patients on the schedule with that history…call them at least 2 days in advance of appt. “Hello, this is ____ from ____. I am calling regarding your appointment on ____ at _____. I need you to please return my call by____ at ____. If I don’t hear back from you by that time we will assume you’ve changed your mind and will cancel your reservation.”

Treatment Plans and Financial Arrangements – Every patient that has an appt. scheduled with the doctor for treatment must have a copy of their treatment plan AND a financial agreement before the appt. Ideally, each patient should receive a copy of the treatment plan and a financial agreement at the time of diagnosis. DON’T ASSUME that the patient is OK with their financial responsibility simply because you gave them a copy of their treatment plan and they didn’t question the cost.  What often happens is they say OK and schedule and then will no-show or cancel at the last minute. OR they come in for the appt. not prepared to pay their portion.

Regarding their financial responsibility – put their co-payment amount in the appt notes so that you remember to remind them to bring it in w/them.

Many patients will not tell you they can’t afford the treatment. MAKE IT EASY FOR THEM TO SAY YES by HELPING THEM FIND A WAY TO WORK IT INTO THEIR BUDGET. The total investment is ____ and we can do it for as little as ___ per month using our partner Care Credit. Have them apply for CC while they are there in the office.

Hygiene Patients – Schedule their next 3, 4, 6-month appt when they are at the office. Take a second to stress to them how important this appointment is and what you’ll be looking for at their next appt. (It’s not just a cleaning.)

VALUE – Walk-Out Statement – Consider itemizing the hygiene appt walk out statement to include the no charge services… ie: Oral Cancer Screening, Nutrition Counseling, Oral Hygiene Instructions, Etc.  Be sure to ALWAYS give the full fee for that day even if they have “100 %” coverage with their insurance. They need to hear the actual dollar amount for each visit. Helps to put more value on the appt.

No-Shows / Late Arrivals – Always acknowledge your no-show/late patients with a call 3-5 minutes past appt. time.  If you get a voice mail – let the patient know you’re concerned because they missed their reservation.  If the patient doesn’t reschedule, send them a kind letter reminding them they were missed and what your office appointment guidelines are for changing appts.  The assistant or hygienist should be making these calls 3 – 5 minutes past appt time. If they can’t make the call right away they are responsible for having someone from the front office make the call for them. Be sure to document the action/ response.

Telephone – The dreaded telephone calls for same-day cancellation attempts from your patients. They can destroy a perfect schedule in a matter of minutes. Stay in control of your schedules by using the following verbiage…

Patient: I’m calling to cancel my appointment for today at 10:00, it’s just for a cleaning.

Admin: (with genuine concern) “Oh no! I hope everything is alright. Jenny was really looking forward to seeing you today for your appointment. Is there any way you can keep your reservation?” or

“Oh no! Thank you for calling, I know Jenny will be concerned, is there anything we can do so that you can be here today?”

or, if you have a broken appointment policy…

Admin: “Oh no! I’d hate for you to have to pay the broken appointment fee, is there any way you can make your reservation with Jenny?”

Now, if the patient is sorry and truly can’t make the appointment and this is the first time they’ve canceled an appointment, say this:

Admin: “I know that Jenny was looking forward to seeing you, I’m sorry that you weren’t able to provide us with 48 hrs advance notice due to (whatever their reason was) – we’ll go ahead and waive the broken appointment fee this time. Let’s get you rescheduled…”

Or if you don’t have a broken appt. policy, say this:

Admin: “We obviously made an appointment for you that isn’t convenient. Since your appointments are important, I want to make sure we never do that again. Is there a time we can schedule that you know will work better with your schedule?”

Document your conversation and that you waived the fee for this time and that the patient is aware next time they’ll be charged.

If the patient refuses to reschedule their appointment…

Admin: “That’s fine, but if I don’t hear back from you, I will call you on ______, how does that sound?” (Follow through on that promise.)

For patients that habitually cancel, I urge you to charge them your broken appointment fee and do not reschedule their appointment.

Admin:  “Mr/Ms (use their name), I can see that you have a really busy schedule and that makes it difficult for you to commit to an appointment time. I thought I was a busy person! What I recommend is that we place you on our “same day” call list. If we have an unexpected change in our schedule, we’ll give you a call. How does that sound?”

Document your conversation! Follow-up accordingly.

Whatever you do and no matter how desperate you are to fill the schedule DO NOT REAPPOINT habitual offenders! You should never be able to look at the schedule and point out who will most likely cancel or no-show.

I’m sure that’s never happened in your office, right? 😉

Work together as a team to come up with scripting that works for your office. Think of all the different scenarios and reasons patients call to cancel (cost, illness, work, no babysitter, schedule conflicts, etc.) and role-play the best responses. Your goal should be, if appropriate, respectfully help the patient find a way to keep the appointment as scheduled without threatening or embarrassing them.

Sending you wishes for a full and productive schedule… one that doesn’t fall apart!

Friends, if you do not know what your office’ broken appointment and reappointment numbers and percentages look like, including how many of your active patients are unscheduled, or how many patients were canceled and not yet rescheduled during COVID, and so many other important key practice indicators; please take note of what those numbers look like. This will help you reopen your practice with a baseline to work from and guide you.  You need to know where you’re at currently to know how to best care for your patients and what your potential for growth is. To help you get that data quickly, like within minutes – if your PMS is either Dentrix, Eaglesoft, or Open Dental you can request a complimentary, no-obligation practice data snapshot here: Game-Changing Awareness from Dental Intelligence  – Within minutes we’ll identify your practice’s strengths and uncover hidden opportunities.  I am happy to assist you with this at no charge.

I would love and truly appreciate for you to please leave a review/recommendation for me here on GOOGLE and/or FACEBOOK.

Don’t miss out on any of the ideas that I share each month! Are you receiving my complimentary Practice Management and Marketing Ideas in your email inbox each month? If not, please start following us today.  If you prefer, send me your email address at bhaydenconsulting@gmail.com and I will send you an invitation to follow my blog.

Yours for Greater Success,

Betty – Dental Coach

P.S. Please stop by and say hello to me on Facebook, Twitter, Instagram, LinkedIn and Pinterest

Dental Marketing and Practice Management Ideas for July 2016
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Dental Marketing and Practice Management Ideas for July 2016

Hello Friends,

Take time now to make plans to start your third quarter off strong. Discuss with your team the plans to reach your production, collection, new patient and marketing goals. Encourage them to share any thoughts or ideas on how you can work to make the third quarter your best yet. Here’s a fun idea…July is National Grilling Month – Why not have a BBQ themed lunch with the team to discuss your marketing plans? Remember to include plans on how to fill and keep the schedule full for August and September as they are typically slower months for some offices.

Doctors, if you don’t already know, I strongly urge you to be aware of your office numbers. Know what’s going on with your patient and insurance aging reports, your daily patient collections, your new patient #’s, referral sources, hygiene continuing care reports, incomplete treatment reports and what internal & external marketing is working and what needs to be eliminated. Don’t leave these things to chance or assume they’re healthy numbers or maybe even beyond repair.

Would you like a few ideas to boost production, collection and new patient numbers? I’ll share with you a couple of ideas to do just that as well as exceed your current patients’ expectations.

dental-marketing-ideas-for-july

July is National Ice Cream Month! Your product/service feature is Desensitizing agents to treat tooth sensitivity. Your give-away treat is free ice cream.

Yes, I’ve shared this one in the past but I’m sharing it again because it is so easy and effective not to mention, delicious.

Why is it so effective? Research finds that 1 in 8 Americans suffer from sensitive teeth. It’s safe to say that many of your patients may be suffering from tooth sensitivity or they know someone who does.

How is it easy? It’s a marketing plan that requires little time, no extra cost and will boost production and exceed your patients (and potential patients) expectations!

How will offering free ice cream not incur any extra cost to you? You simply visit your local ice cream shop and ask them to donate some free ice cream cone certificates. In return, you’ll be advertising for them on your social media site and in the office. Your patients, when they come in for a visit can enter a drawing to win a free ice cream courtesy of “local ice cream shop”. Depending how many free ice cream cone certificates you get donated you can draw one or two names each week for a free ice cream cone.

Now you may not have many of your patients speaking up to say they’re suffering from tooth sensitivity when they eat cold treats or drink cold beverages.

This is what you do, during the month of July have your team members wear buttons that say: Eating Ice Cream Shouldn’t Hurt

Your patients are sure to ask questions about the buttons. What an easy way to open up a discussion about tooth sensitivity.

If you would like further ideas on how to implement the Ice Cream/Tooth Sensitivity campaign such as how to handle patients that are concerned about insurance coverage and fees for desensitizing agents and ways to advertise this campaign or perhaps would prefer a different marketing campaign for the month, please contact me today at bhaydenconsulting@gmail.com.

Here are 3 more ways to help your patients & team smile in July!

July 6,World Kiss Day ~ Blog & Social Media Opportunity (bad breath & kissing, periodontal disease & kissing…eeeww!)

July 7, Chocolate Day ~ I’m sure your team would welcome a surprise chocolately treat.

July 17th – 23rd Everybody Deserves A Massage Week: 

Team up with a local massage therapist for a little cross marketing – have him/her donate a free massage that your patients can enter a drawing to win.

Hope you enjoy these ideas and have a wonderful start to your third quarter!

If you have any other thoughts or ideas please feel free to comment below. Should you need any help with your July marketing campaign, please email Betty: bhaydenconsulting@gmail.com

Have you signed up to receive my complimentary dental marketing and practice management ideas that are sent right to your email inbox each month? If not, take a second and sign up. This way, you won’t miss a single idea! PLEASE, feel free to share my blog with your colleagues. 

Yours for Greater Success,

~Betty

P.S. Please stop by and say hello to me on Facebook, Twitter, Instagram, LinkedIn andPinterest

 

 

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How to Successfully Ask for and Collect Payment for Dental Treatment

Hello Friends,

Fear of cost moves many people to put off visiting the dentist or to cancel their appointments for scheduled treatment. Fear of presenting fees causes many team members to dread or avoid presenting treatment plans/financial expectations and asking for payment. These fears do not help the patient or the office.

Would you like to see more patients not only accept treatment but pay for it before or at time of service?  Would you like to see an increase in production and office collections?  Would you like to decrease the amount of time and money being spent on making collection calls and sending patient statements/letters?

how to ask for and collect dental payments from Betty Hayden Consulting

Today, I’ll share with you a few tips to help make that happen.

  1. See the true value of dentistry – With each day and each and every patient you and your team have the privilege and opportunity to potentially change someone’s life or at the very least, help them smile healthier. A healthy smile is part of a healthy body, healthy smiles and bodies create healthy communities.  The entire team must believe this. The entire team must also wholly believe that you’re providing the best quality care. Having full confidence in the doctors and hygienists ability to provide quality care and to create beautiful and healthy smiles is a must.
  2. Be confident with fees – The entire team should role play presenting small and large treatment plans and financial arrangements until every one is comfortable saying the dollar amounts out loud and with pride.
  3. Financial policy – Have a written financial policy that is kindly reviewed with the patient at their first appt. Have them sign and take a copy with them. For your existing patients, review with them any changes to your financial policies, have them sign and give them a copy to take home.
  4. Avoid assumptions and judgement – Don’t make decisions for the patient as to whether or not they can afford the treatment based on your assumptions or reality. Remember this, Sympathy vs Empathy: Sympathy is feeling for the patient… deciding for them that they can’t afford the dental care, Empathy is feeling with the patient… yes, this is more than they were wanting to pay, however, you’re going to give them hope… you’re going to offer third party financing, break up the treatment plan if possible or allow them to make payments as a credit until they have enough money to get started with treatment. Always offer the best treatment and flexible payment options and allow the patient to decide what they want to accept or not.
  5. No surprises! – Present treatment plan and financial portion before treatment is started. Make sure your numbers are as accurate as possible, especially when estimating the insurance portion. If you accept their insurance, have up to date eligibility, breakdown of benefits and the insurance fee schedule on file for the patient.
  6. Payment due before or on day of service – No billing the patient for co-pays or payment for services. (Hint: Collecting prior to appt. will reduce cancellations and no-shows. Another Hint: Collect co-pay before the patient goes back for treatment, especially if they’re having a lengthy or difficult appt. No one wants to stand at the front desk fumbling for money or to write a check with gauze hanging out of their mouth after an extraction, or numb and exhausted after a long appt. Make it more comfortable for them by collecting their pmt and making any necessary follow up appts before they go back. )
  7. Make it easy for them to pay – In addition to accepting cash, check and charge cards, offer third party financing. Avoid in-office payment plans!
  8. Incentives – Offer incentives for patients to pay when they make the reservation.
  9. Dealing with forgetful patients – When a patient says they forgot to bring money…they can either call the payment in over the phone when they get home or give them an envelope with payment due date for them to mail in a check. Call the patient if payment isn’t received by due date.
  10. When Insurance is involved –  Always give the full treatment fee, the estimated insurance amount and the patient’s estimated co-pay that is due today. Let the patient know you’ll send in the claim and inform them if anything changes with the estimated insurance portion. Watch your insurance aging report closely. Promptly follow up on any unpaid claims, insurance rejections and requests for add’l information.

There you have it, 10 tips to successfully collect payment before or at time of service.

Once you make a plan to consistently collect payments before or at time of service, and hold your team accountable to follow through with that plan, you’ll wish you started it sooner.

Here are a few more tips to help make this a true success for you.

  • Daily, Weekly and Monthly, monitor your patient and insurance accounts receivables, collection and credit reports.  (Carefully review write-off’s, discounts, credits, charges and payments.)
  • Each day, look at the day prior, what were your total production charges & collections? Pay close attention to the total patient responsibility vs patient payments, these numbers should be close to the same. If not, why not?
  • ALWAYS send out clean insurance claims! If your administrative team needs any training in this ever changing insurance world with how to estimate co-pays, send out claims (daily),  post insurance payments and adjustments…get them the proper training asap!
  • Don’t assume… know by who, when, what and how your money is being handled. It’s important for the entire team to understand why this information is necessary.
  • Set goals, share with your team what your production and collection goals are and how it benefits them to all work together as a team to reach or exceed these goals. Consider offering a small bonus or incentive when these goals are reached.

Print out these tips and suggestions and review them at your next team meeting.

Please know, I’m happy to help you and your team develop a plan to reach your production and collection goals. I offer complimentary consultations via email at bhaydenconsulting@gmail.com.

Have you signed up to receive my complimentary dental marketing and practice management ideas that are sent right to your email in box each month? If not, take a second and sign up. This way, you won’t miss a single idea! If you think your dental colleagues would appreciate receiving these ideas each month, feel free to share my blog address with them. Thank you!

Yours for Greater Success,

~Betty

P.S. Please stop by and say hello to me on Facebook, Twitter, Instagram and Pinterest