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* 1. Thank you for participating in this survey. What is your primary occupation on the date of completing this survey?

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* 2. In what country do you currently reside?

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* 3. Rate yourself on how much you agree/disagree with the following statements.

  Strongly disagree Disagree Neutral Agree Strongly agree
I don’t feel like I have enough training to discuss financial arrangements.
I don’t feel comfortable stating the fee to the patient.
I don’t like asking for payment at time of service.
It’s not my job to talk about fees, finances, and/or money.
I’m afraid to let the patient know we do not accept assignment of benefits.
I don’t want to be responsible for negotiating payment plans and/or financial arrangements.
I’m uncomfortable saying “no” when the patient asks for a discount.
I don’t want to have to learn about the offices’ financial policy/guidelines.
I don’t want to have to develop a financial policy/office guidelines.
I don’t know what to say when a caller requests a fee quote over the phone.
I don’t know what to say when I sit down with a patient to discuss financial arrangements or inform him/her that payment is expected.
I don’t like charging for broken appointments.
I don’t want to have to collect the patient’s portion from the unpaid balance.
If I talk about fees or money, I’m afraid the patient will judge me for being too sales oriented.
I prefer to submit a pre-determination of insurance benefits rather than talk about financial arrangements.
I feel resentful about people making more money than I do.
I pay bills late.
It is awkward to let the patient know the fee will be higher than the initial quote for treatment changes.
I decide in advance that a patient can’t afford to pay for my services.
I’m afraid of offending the patient if I talk about finances or fees.
I don’t like discussing money with my family, spouse, and/or partner.
I’m reluctant to discuss with my spouse/partner or family why I am creating debt to invest in my practice, education, business, etc.
I spend as much as I make.
I’m uncomfortable discussing debt with creditors.
I’m afraid to ask for a raise and/or negotiate my salary.
I’m reluctant to increase my fees.

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* 4. If you experience a situation or conversations related to case acceptance not described above, please tell us about it here.

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* 5. We invite you to comment on the dental hygienist's role in case acceptance. We are interested in hearing about trends in your office, or just your perspective about financial arrangement with patients.

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