Transition Practice Profile

General Information:

Is the practice sale confidential?(Required)

Yes

First Name(Required)

Last Name(Required)

Corporate Name:(if applicable):

Office Address(Required)

City(Required)

State(Required)

Zip(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Degree(Required)

DDS

DMD

Dental School(Required)

Graduation Date(Required)

Email(Required)

Mobile

Are any team members aware of sales?(Required)

Yes

Please List(Required)

Name

Patient Base:

Total active patients (Past 18 months)(Required)

Number of ADA code D0110 (Past 18 months)(Required)

Average number of new patients per month (Past 12 months)(Required)

Total number of patients younger than 18 years old(Required)

Approximate percentage of practice income:(Required)

Full Fee (%)

PPO (%)

Medicaid (%)

HMO/Capitation (%)

List Insurance plans which you are contracted and in network with:(Required)

Equipment

Hand Delivery(Required)

Right

Left

Interchangeable

Average Age of Equipment (In years)(Required)

Number of Wall Mounted X-Rays(Required)

Number of Mobile X-Ray Units(Required)

Number of Intraoral Cameras(Required)

Digital Panorex(Required)

Yes

Model of Laser(Required)

Yes

CADCAM(Required)

Yes

Nitrous(Required)

Not avialable

Mobile Unit

Plumbed but Not in Use

Plumbed & in Use

Scanner(Required)

Yes

CBCT(Required)

Yes

Name of Practice Software(Required)

Number of Work Station(Required)

Each Operatory & Front Desk

Completely Paperless

Number of Computers at front desk(Required)

Number of Computers in opps:(Required)

Number of Computers in other work stations (CBCT, doctor office, etc.)(Required)

Facility

Number of equipped operatories for dentist(s)(Required)

Number of equipped operatories for hygiene department(Required)

Total equipped operatories (add Dentist Ops + Hygiene Ops)(Required)

Additional number of operatories plumbed but not equipped(Required)

Facility Space (sq ft)(Required)

Is Facility Expandable(Required)

Yes

Type of Building(Required)

Condominium

Free Standing Building

Multi Tenant Building

Professional Building

Shopping Center

Other

Do you share space with another doctor or practice?(Required)

Yes

Do you own the real estate?(Required)

Yes

Is the real estate available for purchase?(Required)

Yes

Describe Sales Price(Required)

For Lesee

Current Monthly Lease Rate(Required)

Common area, maintenance fees/ taxes included?

Yes

If not included, current amount paid?

If applicable, additional monthly expenses paid by Lesee

Taxes

Insurance

Maintanance

Are utilities included?(Required)

Yes

Lease Expiration Date(Required)

MM slash DD slash YYYY

Is Lease Assignable(Required)

Yes

Are there Options to Renew?(Required)

Yes

Renew Options(Required)

Number of options

Length of option term (in years)

Practice History

Office Operation Information

Office Hours

SUN

MON

TUE

WED

THUR

FRI

SAT

Doctor's Hours

SUN

MON

TUE

WED

THUR

FRI

SAT

Hygienist Hours

SUN

MON

TUE

WED

THUR

FRI

SAT

Type of Practice(Required)

Reason for selling(Required)

Year established(Required)

Days worked in previous year(Required)

Year practice was established in current area(Required)

Year practice was established in current location(Required)

Do you purchase your practice?(Required)

Yes

If so, when?(Required)

Do you work in another practice?(Required)

Yes

If so, what is the address?(Required)

Has there been a Partner in the practice within the last 3 years?(Required)

Yes

If 'Yes', have they signed a covenant not to compete?(Required)

Yes

Has there been an Associate in the practice within the last 3 years?(Required)

Yes

If 'Yes', have they signed a covenant not to compete?(Required)

Yes

Collections

Annual Gross Collections by provider for the previous tax year:(Required)

Year

Dentist Collection(s)

Hygienest(s)

Total(s)

Any in house speciality collection?

General Information:

How many Dentists currently work in the practice?(Required)

How many days per week does each doctor work:(Required)

What is the current number of hygienist working in the practice:(Required)

List the number of days each hygienist works per week:(Required)

After the sale, how long would the owner prefer to work in the practice? (in months):(Required)

Production Breakdown by Category:

Diagnostic %:

Preventive %:

Restorative %:

Endodontics %:

Periodontics %:

Prosthontics/Removable %:

Maxillofacial Prosthetics %:

Implant Services %:

Prosthodontics/Fixed %:

Oral Surgery %:

Othodontics %:

Adjunct General Services %:

Other (please specify) %:

Procedures Referred Out:(Required)

Plans following the sale of the practice:(Required)

Unique benefits that add value to the practice:(Required)

Any disciplinary actions received in the past ten years?(Required)

Yes

Any suits filed against owner in the past ten years?(Required)

Yes

Staff Information

Individuals employed by the practice (including family members that receive salary)

Name

Position

Annual Salary

Year Hired

Hours Worked Weekly

Family Member? (Yes/No)

List all family members who work as unpaid employees. Describe position, schedule, and duties:

Name

Position

Year Hired

Hours Worked Weekly

List any staff who anticipate leaving after the transition of the practice:

Name

Position

*SELLER IN NO WAY WARRANTS THE EXACT ACCURACY OF PATIENT FILES. IT IS THE BUYER'S RESPONSIBILITY TO DEFINE AND VERIFY ACTIVE PATIENT FILES WITH A CHART REVIEW. PRACTICE VALUE IS PREDOMINANTLY DETERMINED BY SELLER'S COLLECTIONS. SELLER'S COLLECTIONS CAN BE INDICATIVE OF THE NUMBER OF ACTIVE PATIENTS AND TYPE OF PROCEDURES PERFORMED.

To the best of my knowledge, all of the information I have or will provide to Dental Medical Careers is accurate and correct.

Please Print Your Name(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

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Transition Practice Profile

General Information:

Patient Base:

Equipment

Facility

For Lesee

Practice History

Office Operation Information

Collections

General Information:

Staff Information

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