Ambassador Launch Information
To be completed by the team when you feel an on site visit would be beneficial for the office. The intent of this document is to communicate all pertinent information from the eAssist team regarding the status of the office to the Ambassador. The Ambassador will provide an Assessment upon completion of the visit. Please provide as much information as possible. Your honesty and integrity is valued and appreciated in this experience. Thank you!
Name of person requesting Ambassador (your name):
First Name
Last Name
Your email (the system will send a copy of this form to this email):
example@example.com
Your Team Mate's email address:
example@example.com
Your Team Leader's email address:
example@example.com
Name of Office:
Name of your Ambassador:
Email address of your Ambassador:
example@example.com
City & State office is located in:
Name of Zulip channel:
Office Address:
Office phone number:
Dr's name & cell phone:
Dental Software used:
Are they a previous eAssist client?
Yes
No
Not sure
Is this a start up office?
Office hours, days open, days in office without patients:
Number of staff members currently:
Your main contact at the office & other staff that we might talk to:
Have you sent an email to the office introducing your Ambassador?
Yes, and they acknowledged receipt
Yes, but I'm not sure they read it
Not yet, but just did; thanks for the reminder!
Other
This is a launch office, please rate the level of difficulty of start up:
Extremely difficult, many issues, office starting off rocky (aka "SC/RP")
Small issues that would benefit from an in person visit (aka "FMD")
The launch has been seemless so far (aka "PROPHY")
Other
Notes of explanation (please provide detailed information if other than a "prophy" visit):
Please rate the QUALITY of the KOC:
1
2
3
4
5
Notes about KOC experience:
How does the office feel about us coming on board?
Enthusiastic, they can't wait!
On board
Slightly reluctant
Opposed
Other
Is the office in financial distress?
Yes
No
Unsure
Please rate the current QUANTITY of communication you have with the office:
1
2
3
4
5
Please rate the current QUALITY of communication you have with the office:
1
2
3
4
5
Notes on Communication:
Please rate the QUALITY of relationship you have with the office:
1
2
3
4
5
Notes on RELATIONSHIP with the office:
Please describe any IT issues:
Is the office knowledgeable about their software?
Yes, proficient
Yes, and could use help
No, not really
No, brand new and need help
Other
Are there any questions or concerns you would like us to address with the office?
What would you like to see come of this Ambassador visit?
Please upload current aging report with notes:
Browse Files
Cancel
of
Please note any trends or explanations of figures on reports; your analysis:
Has the office been visited before?
YES
NO
Unsure
Other
Can you provide any insight into the office's preferences for treats or any requests from you? (special diets)
PLEASE MAKE SURE BARB LITTLE IS IN
YOUR ZULIP CHANNEL
I am complete.
Should be Empty: