Application Step 1 of 3 - Getting Started 0% HiddenListing ID Name* First Last Home Street Address* City* State*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* What year was the practice founded?* How was the practice started? Purchased from another doctor? Startup?*Do you use any type of sedation (nitrous, IV)?* Do you accept Medicaid?*YesNoIf so, roughly what percentage of collections is Medicaid? Is your office mercury free?*YesNoAre you incorporated? If yes, please email us a copy of your Articles of Incorporation.YesNoEmployees*NamePostitionYear HiredExpected to stay?Annual Value of BenefitsHourly Rate% of CollectionsIs this employee family? How many parking spaces are there?* Do you have a lease? If yes, please email us a copy of the lease.*YesNoWhat is the office square footage?* How many operatories do you have?*Are all operatories in use? How many do dentists use? How many do hygienists use?*Are you right or left handed?*Right HandedLeft HandedAmbidextrousWhat practice management software and recall system do you use? (Ex. Eaglesoft, Softdent, etc.)* Dental Chair(s)*MakeModelApproximate Age (Years)Quantity Dental Unit(s)*MakeModelApproximate Age (Years)Quantity Dental Light(s)*MakeModelApproximate Age (Years)Quantity Dental X-Ray Sensor(s)*MakeModelApproximate Age (Years)Quantity CAD/CAM(s)*MakeModelApproximate Age (Years)Quantity Panoramic X-Ray(s)*MakeModelApproximate Age (Years)Quantity Scanner(s)*MakeModelApproximate Age (Years)Quantity New Technology Purchases*MakeModelApproximate Age (Years)Quantity Financial Adjustment QuestionsAre any family members or anyone who doesn't directly contribute to the practice receiving a salary or benefits? Who? Amounts?*Are there any personal supplies being charged to the business? (I.E., paper towels. etc.)*Are there any building repairs or material purchases not used for the practice? If so, what are they?*Are there any non-practice utilities such as internet or cell phones being charged to the business? If so, we need to know what they are and amounts.*Are there any legal or professional fees being charged to the business that were not for the practice directly? If so, we need amounts.*Can you break down the "insurance" line item? In other words, what part of insurance is for personal, spouse, staff etc.? We need this broken out and the amounts.*We need the same breakout for benefits as Question 6. What benefits are personal and what benefits are for staff?*Is there any equipment you are currently renting or any equipment that needs repair?*Are you paying fair market rent? (Only answer if you own the building and paying yourself rent)NameThis field is for validation purposes and should be left unchanged.
