Please note: All fields marked * must be completed.
Objectives for Conversion:

Please list your main objectives for conversion:
1) 3)
2)
       
Your Practice Details
* Town
* County
* Postcode
Denplan Member No. *
* *
Address line 1 Website address
Address line 2 Telephone - Home
Address line 3 Telephone - Mobile
       
Patient Numbers

Please enter the number of patients you are currently seeing per annum (p.a). This can be found in your “End of Year Statement of Activity” under the section “Analysis of Patients Treated by Patient Charge Status”.

Enter the average number of minutes spent p.a  with each patient type:
Patient split Patients Average mins
*
*
*
Financial Details
Please enter your current income from NHS patients, any private income that you currently earn from NHS patients and any additional income you would like. This is also an opportunity to consider additional investment for the practice and ensure that any additional expenditure on preventive care is covered in your patient fees:
Finances  
*
Private Income earned from NHS Patients p.a. (£)
Percentage Increase required (%)
Total Additional Investment p.a.(£)
Total Additional Hygienist Cost p.a. (£)
UDA Target (England and Wales only)
Enter your current annual UDA target:
Target UDAs  
Total UDA Target
Under "Analysis of Patients Treated by Patient Charge Status" you will find the following information split by patient type. Please enter these figures:
Number of UDAs Processed    
Child  
Exempt or remitted Adult  
Non-exempt Adult  
Total for Contract   over     months
Working Hours
Enter the weeks and hours that you currently spend with your patients and the time you would like to work in the future. This will ensure that your target number of Denplan patients will be able to be seen within your preferred working times:
Hours split  
*
*
*
*
Laboratory Fees
Enter your annual laboratory fees for all work currently undertaken under the NHS:
Lab Fees  
*
Children’s Fees
If you want to offer a children’s plan at a lower rate, please enter the percentage reduction compared to adult fees:
Child rates  
Percentage reduction (%)
Thank you for completing this form.
You have now provided enough information to enable Denplan to provide a financial report which will show you just how easy it is to convert your NHS patients using our capitation plan, Denplan Care.

Please click on the 'Submit this form' button to send this form to one of our consultants who will be in touch with you shortly.

If you experience any difficulties completing this form, please contact the Denplan Practice Support Team on 0800 328 3223.