Practice Transition Questionnaire

Home » Practice Transition Questionnaire

Step 1 of 10

10%

General Information
Owner's Name*
First Last
Dental School*
Year of Graduation*
Practice Legal Name*
Practice Principal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
All correspondence should be sent*
- Home Address
- Office Address
Office Phone*
Home Phone
Cell Phone*
Office Fax
Email*
Is your email private?*
- Yes
- No
If we need to contact you, do you prefer to be contacted by*
- Email
- Office Phone
- Cell Phone
- Home Phone
Practice Website Address*

Please identify practice owner(s) and ownership percentage*

Name	% of Ownership	Name	% of Ownership

must equal 100%

Practice is operated as*
- Sole Proprietorship
- Professional/Service Corporation(PC/SC/Inc./Ltd.)
- Partnership
- "C" Corporation
- "S" Corporation
- LLC-Limited Liability Co.
- PLLC-Professional Limited Liability Co.
- PLLP-Professional Limited Liability Partnership
If incorporated or partnership, date of information
Practice Type*
Ex: General Dentistry
Does practice philosophy lean towards any particular emphasis, such as*
- TMJ
- Non-Amalgam
- Holistic
- Pankey Philosophy
- Other
If other, please specify*
Purpose of Valuation*
- Financial Planning
- Possible Outright Sale
- Divorce
- Sale to Current Associate
- Other
If other, please specify*
If sale is anticipated, timetable for sale
Does staff know?
- Yes
- No

Save and Continue Later

Average number of new patients seen per month for past 2 years*
Total patients seen year-to-date*
Period covered*
i.e., 1/12-4/12

What is the percentage of the source from which new patients are derived?*

Existing Patients	Website	Advertising (type)	New Insurance Plans	Other Dental/Medical Providers	Other Sources

must equal 100%

Who are your practice's major competitors?*
What impact have they had on your practice receipts?*
Does practice employee a hygienist?*
- Yes
- No
If yes, number of hygiene days per week?*
ex: one hygienist working 3 days and another working 4 days equals 7 total days
Average number of patients seen per day per hgienist
Estimated percentage of practice consisting of patients under age 16*
Historically, which month has been the practice's most productive?*
(Jan-Feb)
Historically, which month has been the practice's least productive?*
(Jan-Feb)

Office hours:*

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

How many hours is the practice open per week?*
How many weeks are you scheduled in advance?
If you have an associate or partner, how many weeks in advance is he/she scheduled in advance?
How many weeks is/are your hygienist(s) scheduled in advance?

Please estimate percentage of revenue generated in each category*

Hygiene (including x-rays)	Provided by Doctor	Provided by Hygienist	Total % of revenues-Hygiene related	Restorative(excluding single crowns)	Crown & Bridge	Endodontics	Pediatrics

Must equal 100%

Save and Continue Later

Percentage Revenue cont'd

Periodontics	Oral Surgery	Orthodontics	Removable Prosthetics	Implants	Invisalign	Product Sales	Other

Must equal 100%

Save and Continue Later

Please estimate the approximate percentages of revenue sources in your practice:

100% out of pocket from patient	Insurance plans (indemnity)	PPOs	HMOs	Medicaid	Other Sources

Must equal 100%

What is your co-pay at time of service policy?
Are you a Delta Premier provider?*
- Yes
- No
If yes, what percentage of your receipts consist of Delta Premier?*

Please list below the annual insurance premiums that you pay through your practice as an owner:*

Malpractice Insurance	Premises/Liability Insurance	Workmen's Comp	Office Overhead	Staff Health Insurance	Personal Disability Insurance	Life Insurance	Disability Buy-Out Insurance	Owner Health Insurance	Other

Save and Continue Later

Additional Information
Please list any additional information
Please use back of form or attach pages as needed
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Associate Name	Hire Date	Hours Week	Monthly Production

Practice Transition Questionnaire

Step 1 of 10

General Information

Practice History

Community Factors

Facilty Factors

Practice Statistics

Staff Information

Financial Information

Additional Information

Have Questions?

Schedule a call with one of our consultants today to find out how we can help!

We Are Here To Assist You

Schedule A Consult