Application

Step 1 of 19 - Getting Started

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
- We will be in touch to coordinate a time to access your Practice Management Software to gather needed practice reports

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Name*
First Last
Degree*
Date of Birth*
Date Format: MM slash DD slash YYYY
Practice Trade Name*
GP or Specialty*
Incorporated?*
Corporation Suffix*
Corporation Type*
Web Address*
Practice Street Address*
Practice City*
Practice County/ Parish*
Practice State*
Practice Zip Code*
Practice Phone*
Practice Fax Number*

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Home Street Address*
City*
State*
Zip*
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?*
How was practice started?*
Year Beginning Practice in Current Location*
Purchased from*
In what year?*
Associate(s)?*
Partner(s)?*
Do you share space?*
Has an associate or partner left your practice in the last 2 years?*
When?
Is there an assignable restrictive covenant?*
Please Describe

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Is there an assignable restrictive covenant?*
Please Describe
Is there an assignable written agreement?*
Please Describe
Is there a buy-out agreement?*
Please Describe

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Office sq. ft.*
Expandable sq. ft.*
Is Office Handicapped Accessible?*
Number 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?*
Real Estate Information
Do you want to sell the building?*
Legal Name of Owner*
Annual Property Taxes*
Annual Property Insurance*
Was the building appraised?*
When was the appraisal?*
What is the appraised amount or estimated value?*
Lease Information
Lease 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?*
Describe Lease renewal/ Purchase options*

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Number of days per week you currently work*
What is your ideal post-sale scenario?*
Do you plan to work operative post-sale?*
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*

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Has the practice been appraised?*
When was the appraisal?*
What was the appraised amount?*
Have you previously tried to sell your practice?*
When?*
Date Format: MM slash DD slash YYYY
Did you use a broker?*
Who was the previous broker?*
Is your practice currently listed with another broker?*
Who is your current broker?*
Has your practice gross changed significantly?*
Please explain the change in gross*
Describe any internal marketing*
Describe any external marketing*

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Did you provide the following?
Nitrious Oxide*
Counscious Sedation or DOCS*
IV Sedation*
Mercury Free*
How 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)*

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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

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Mon
- Closed Monday
__________Open__________

: HH

MM
_______Lunch________
__________Close__________

: HH

MM
Tues
- Closed Tuesday
__________Open__________

: HH

MM
_______Lunch_______
__________Close__________

: HH

MM
Wed
- Closed Wednesday
__________Open__________

: HH

MM
_______Lunch_______
__________Close__________

: HH

MM
Thurs
- Closed Thursday
__________Open__________

: HH

MM
________Lunch________
__________Close__________

: HH

MM
Fri
- Closed Friday
__________Open__________

: HH

MM
________Lunch________
__________Close__________

: HH

MM
Sat
- Closed Saturday
__________Open__________

: HH

MM
________Lunch________
__________Close__________

: HH

MM
Sun
- Closed Sunday
__________Open__________

: HH

MM
________Lunch________
__________Close__________

: HH

MM
What type of recall system do you use?*
What type of practice management software do you use?*

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Major Employers in the area:
Describe any major economic changes in your drawing area.*

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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*
Postition Year Hired Expected to stay? Annual Value of Benefits Hourly Rate % of Collections Is this employee family?

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Employees*
Postition Year Hired Expected to stay? Annual Value of Benefits Hourly Rate % of Collections Is this employee family?

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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?

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Does practice meet OSHA standards?*
If not, why?
Does practice meet HIPAA standards?*
If not, why?
Have you had any practice-related lawsuits filed against you in the past seven years?*
If yes, why?
Have your received any disciplinary actions in the past seven years?*
If yes, why?
Are there any health problems that could affect your practice of dentistry?*
If yes, why?
Do you forgive any insurance co-payments?*
Approximately what % of your collections is forgiven?
If yes, why?

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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:*

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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:*

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Total Annual Pension Expense
Annual Staff Pension Expense:*
Annual Owner Pension Expense:*
Total Annual Expenses for Pension:*

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Equipment Inventory
Please use this section to list all equipment inventory in your practice.
NA*
Please enter all dental chairs in your practice.
Not Available Room Make Model Approx. Age Quantity
Dental Unit*
Please enter all dental units in your practice.
NA Room Make Model Approx. Age Quantity
Dental Light*
Please enter all dental lights in your practice.
NA Room Make Model Approx. Age Quantity
Dental Cabinets*
Please enter all dental cabinets in your practice.
NA Room Make Model Approx. Age Quantity
Dental Stools*
Please enter all dental stools in your practice.
NA Room Make Model Approx. Age Quantity
X-Ray*
Please enter all x-ray machines in your practice.
NA Room Make Model Approx. Age Quantity
Please describe your practice, staff, patients, community, and practice philosophy.*
Email
This field is for validation purposes and should be left unchanged.

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Postition	Year Hired	Expected to stay?	Annual Value of Benefits	Hourly Rate	% of Collections	Is this employee family?

Postition	Year Hired	Expected to stay?	Annual Value of Benefits	Hourly Rate	% of Collections	Is this employee family?

What benefits do you provide to the employees?	What is the total cost of these benefits to the practice annually?

Not Available	Room	Make	Model	Approx. Age	Quantity

Step 1 of 19 - Getting Started

Real Estate Information

Lease Information

Enter the number of days per week you wish to work for the buyer after the sale:

Did you provide the following?

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Annual Insurance Expense

Annual Tax Expense

Total Annual Pension Expense

Equipment Inventory