Application Step 1 of 19 - Getting Started 0% Listing ID In addition we need the following: Previous 3 years of corporate tax returns Drop files here or YTD P&L (CPA generated if possible) Drop files here or Payroll Summary Report (previous 3 years and YTD) Drop files here or Name* First Last Degree*Select Degree...NAMDDDSDMDDate of Birth* Date Format: MM slash DD slash YYYY Practice Trade Name*GP or Specialty*Select GP or Specialty...NAGeneral PracticeOrthodontic PracticeOral Surgery PracticePeriodontal PracticeProsthodontistEndodontistPediatricIncorporated?*SelectNAYesNoCorporation Suffix*Please SelectNASPGPLPLLPLLLPLLCPLLCOtherCorporation Type*Please SelectNACSWeb Address*Practice Street Address*Practice City*Practice County/ Parish*Practice State*VirginiaPractice Zip Code*Practice Phone*Practice Fax Number* Home Street Address*City*State*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*Accountant/ Company*Accountant Phone*Accountant Fax*Accountant Email* Attorney/ Law Firm*Attorney Phone*Attorney Fax*Attorney Email* Dental School Alma Mater*Year Graduated*Right or Left handed?*SelectRightLeftAmbidextrousHow was practice started?*SelectNAPurchaseStartupYear Beginning Practice in Current Location*Purchased from*In what year?*Associate(s)?*SelectNA012345678910+Partner(s)?*SelectNA012345678910+Do you share space?*SelectNAYesNoNot AvailableHas an associate or partner left your practice in the last 2 years?*SelectNAYesNoNot AvailableWhen?SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIs there an assignable restrictive covenant?*SelectNAYesNoNot AvailablePlease Describe Is there an assignable restrictive covenant?*SelectNAYesNoPlease DescribeIs there an assignable written agreement?*SelectNAYesNoPlease DescribeIs there a buy-out agreement?*SelectNAYesNoPlease Describe Office sq. ft.*Expandable sq. ft.*Is Office Handicapped Accessible?*SelectNAYesNoNumber of Parking Spaces*Number of Equipped Operatories*Number of Operatories Used Primarily by Hygienists*Number of Operatories Used Primarily by Dentists*Number of Unplumbed and Empty Operatories*Number of Plumbed but Unequipped Operatories*Do you or your entity own the building?*SelectNAYesNoReal Estate InformationDo you want to sell the building?*SelectNAYesNoLegal Name of Owner*Annual Property Taxes*Annual Property Insurance*Was the building appraised?*SelectNAYesNoWhen was the appraisal?*SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat is the appraised amount or estimated value?*Lease InformationLease Start Date* Date Format: MM slash DD slash YYYY Lease End Date* Date Format: MM slash DD slash YYYY Monthly Rental Amount*Is there an option to purchase?*NAYesNoDescribe Lease renewal/ Purchase options* Number of days per week you currently work*What is your ideal post-sale scenario?*Do you plan to work operative post-sale?*NAYesNo Enter the number of days per week you wish to work for the buyer after the sale: In the first year*In the second year*In the third year* Has the practice been appraised?*NAYesNoWhen was the appraisal?*SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat was the appraised amount?*Have you previously tried to sell your practice?*NAYesNoWhen?* Date Format: MM slash DD slash YYYY Did you use a broker?*NAYesNoWho was the previous broker?*Is your practice currently listed with another broker?*NAYesNoWho is your current broker?*Has your practice gross changed significantly?*NAYesNoPlease explain the change in gross*Describe any internal marketing*Describe any external marketing* Did you provide the following? Nitrious Oxide*NAYesNoCounscious Sedation or DOCS*NAYesNoIV Sedation*NAYesNoMercury Free*NAYesNoHow many different patients have you treated in the last 18 months?*How many new patients per month?*Average number of patients treated per day by dentists?*Average number of patients treated per day by hygienists?*% of practice income from cash? (Fee for Service)*% of practice income from Preferred Provider Insurance (PPO)*How many plans are you enrolled in? (PPO)*% of practice income from Non-referred Provider Insurance?*% of practice income from Capitation?*How many plans are you enrolled in? (Cap)*% of practice income from Medicaid?*How many plans are you enrolled in? (Med)* To change number of plans, go to previous page (Practice B) and adjust number of plans. Preferred Provider Plans % of Normal Fee No Plans Capitation Plans % of Normal Fee No Plans Medicaid Plans % of Normal Fee No Plans Mon Closed Monday __________Open__________ : HH MM AM PM _______Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Tues Closed Tuesday __________Open__________ : HH MM AM PM _______Lunch_______Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Wed Closed Wednesday __________Open__________ : HH MM AM PM _______Lunch_______Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Thurs Closed Thursday __________Open__________ : HH MM AM PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Fri Closed Friday __________Open__________ : HH MM AM PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Sat Closed Saturday __________Open__________ : HH MM AM PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM Sun Closed Sunday __________Open__________ : HH MM AM PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : HH MM AM PM What type of recall system do you use?*What type of practice management software do you use?* Major Employers in the area: Describe any major economic changes in your drawing area.* Please use this section to list all direct employees and contractors. Do not include contracted services (such as janitorial, maintenance, equipment and tool cleaning services, etc). Continue the list on 'Staff (2)'. If additional space is needed please use the 'Additional Information' tab to list more employees and salaries. Please click the ㊉ symbol to add row. Employees*PostitionYear HiredExpected to stay?Annual Value of BenefitsHourly Rate% of CollectionsIs this employee family? Please click the ㊉ symbol to add row. Employees*PostitionYear HiredExpected to stay?Annual Value of BenefitsHourly Rate% of CollectionsIs this employee family? Please click the ㊉ symbol to add row. Benefits*What benefits do you provide to the employees?What is the total cost of these benefits to the practice annually? Does practice meet OSHA standards?*NAYesNoIf not, why?Does practice meet HIPAA standards?*NAYesNoIf not, why?Have you had any practice-related lawsuits filed against you in the past seven years?*NAYesNoIf yes, why?Have your received any disciplinary actions in the past seven years?*NAYesNoIf yes, why?Are there any health problems that could affect your practice of dentistry?*NAYesNoIf yes, why?Do you forgive any insurance co-payments?*NAYesNoApproximately what % of your collections is forgiven?If yes, why? Annual Insurance Expense Annual Owner Health Insurance:*Annual Staff Health Insurance:*Annual Owner Life Insurance:*Annual Malpractice Insurance:*Annual Owner Personal Benefits (disability, etc...):*Total Annual Expense for Insurance:* Annual Tax Expense Annual Staff Payroll Tax:*Annual Owner Payroll Tax:* Total Annual Payroll Tax:*Annual Ad Valorem/ Property Taxes:*Annual Real Estate Taxes:*Total Annual Expenses for Taxes:* Total Annual Pension Expense Annual Staff Pension Expense:*Annual Owner Pension Expense:*Total Annual Expenses for Pension:* Equipment InventoryPlease use this section to list all equipment inventory in your practice. NA*Please enter all dental chairs in your practice.Not AvailableRoomMakeModelApprox. AgeQuantity Dental Unit*Please enter all dental units in your practice.NARoomMakeModelApprox. AgeQuantity Dental Light*Please enter all dental lights in your practice.NARoomMakeModelApprox. AgeQuantity Dental Cabinets*Please enter all dental cabinets in your practice.NARoomMakeModelApprox. AgeQuantity Dental Stools*Please enter all dental stools in your practice.NARoomMakeModelApprox. AgeQuantity X-Ray*Please enter all x-ray machines in your practice.NARoomMakeModelApprox. AgeQuantity Please describe your practice, staff, patients, community, and practice philosophy.*PhoneThis field is for validation purposes and should be left unchanged.
