Data Collection Form


Office..........................................
Month, Year ..........................................
Doctor ..........................................

Production
   Professional Services ..........................................
   Eyewear Sales ..........................................
   Contacts ..........................................

Total Receipts ..........................................

Patients
   New ..........................................
   Established ..........................................

Fee generating Visits ..........................................

Fee generating appt slots available ..........................................

Doctors hours ..........................................

Practice hours ..........................................

Staff hours ..........................................

Cost of Goods Sold
   Frames ..........................................
   Labs Work ..........................................
   Contacts ..........................................
   Other ..........................................

Operating Expenses
   Occupancy ..........................................
   Payroll ..........................................
   Advertising ..........................................
   Other ..........................................

Accounts Receivable balance ..........................................

Web Hits ..........................................

Shopper converstion rate
   Calls ..........................................
   Appointments ..........................................

Recall:
   Patients Contacted ..........................................
   Patients Reached ..........................................
   Appointments Made ..........................................

Referrals ..........................................

# Patients buying multiple pairs ..........................................

Contact Lens Fit/Refit ..........................................



Production
Gross Sales or Gross Charges. Track daily, report weekly numbers at weekly office meeting, report monthly here. Track daily production needed to reach monthly goal. If possible, breakdown into Professional Services, Eyewear Sales, and Contacts.

Revenue
Total Cash Receipts. Track daily, report weekly, report monthly total here.

Total Patients
Number of fee-generating patients seen (comprehensive and intermediat exams). Do not include CL follow-up, post ops, or miscellaneousn ofee visits. Break down by "New Patients" and "Established Patients". Track weekly and report here monthly.

Appointment Slots
Number of actual "fee generating" appointment slots available. Tracked daily, reported weekly at team office meeting, reported monthly here.

Doctor Hours
Number of hours the doctor(s) are available to see patients for the month.

Practice Hours
Number of hours the office is open for the month.

Staff Hours
Number of total staffing hours worked for the month.

Cost of Goods Sold
Dollars spent on supplying frames, contact lenses, lab work, and misc.

Operating Expenses
Total monthly expenses such as staff salary, rent, utlities.

Occupancy Costs
Rent, insurance, utilities, maintenance, and janitorial costs.

Payroll Costs
Payroll, payroll taxes, bonuses, insurance, continuing education, profit sharing, and uniforms.

Advertising Costs
All advertising, marketing, and promotion costs.

Accounts Receivable Balance
End of month amount of outstanding receivables.

Web Hits
Total hits to website as reported by VisionSource or your web master.

Shopper Conversion Rate
Number of "shopper" phone calls compared to number of appointments made from those phone calls.

Practice Cost per Practice Hour
(Cost of Goods Sold + Operating Expenses) / Practice Hours

Chair Cost per Doctor Hour
70% Operating Expenses / Doctor Hours

Dispensary Cost per Practice Hour
30% Operating Expenses / Practice Hours

Net Margin on Sales
The dispensary’s profit divided by the total revenue from product sales. (Profit = gross revenue minus costs of goods, staff costs, marketing costs, space costs and overheads.) A net margin of less than 15% indicates the dispensary is not maximizing profit potential. A financially effective dispensary should produce a net margin of 25% or better.



Date # of fee
slots		 new pt
visits		 estab pt
visits		 new pt
contact visits		 estab pt
contact visits		 total
pt visits		 fee
no shows		 no fee
prog checks
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