Practice Transition QuestionnaireStep 1 of 1010%General InformationOwner'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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country All correspondence should be sent* Home Address Office AddressOffice Phone*Home PhoneCell Phone*Office FaxEmail* Is your email private?* Yes NoIf we need to contact you, do you prefer to be contacted by* Email Office Phone Cell Phone Home PhonePractice Website Address*Please identify practice owner(s) and ownership percentage*Name% of OwnershipName% 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 PartnershipIf incorporated or partnership, date of informationPractice Type*Ex: General DentistryManagement Consultant in the last 5 years?* Yes NoDescribe results*Does practice philosophy lean towards any particular emphasis, such as* TMJ Non-Amalgam Holistic Pankey Philosophy OtherIf other, please specify*Purpose of Valuation* Financial Planning Possible Outright Sale Divorce Sale to Current Associate OtherIf other, please specify*If sale is anticipated, timetable for saleDoes staff know? Yes NoIf sale, will seller continue with practice after sale?* Yes NoIf yes, Seller's required number of clinical hours per week after sale?*Will seller's ongoing employment be a condition of sale?* Yes NoDesired work days/week 1st year?*Desired work days/week 2nd year?*Desired work days/week 3rd year?*Desired work days/week 4th year?*Desired work days/week 5th year?*Desired work days/week 6th year?*Does practice owner(s) operate any satellite/additional offices?* Yes NoIf yes, please identify location(s)*Do offices file seperate tax returns?* Yes NoHow far is/are satellite office(s) located from primary office?*Practice HistoryHow was practice aquired?* Started by present owner PurchasedDate practice was started or acquired?* MM DD YYYYIf practice was purchased, what was the previous owner's name?*How long did previous owner practice?*Has practice ever acquired/merged any other practice into operation?* Yes NoIf yes, when?*By what percentage did practice gross receipts increase after acquisition?*Acquisition price?*Previous average gross of practice acquired?*List any other significant dates or events in the practice historyOwner hours worked per week*How many patient contact days did employed/owner dentist(s) provide year-to-date?*Prior calendar year?*Number of vacation/sick days taken by owner year-to-date*Prior calendar year?*Have there been any malpractice claims within the last 5 years?* Yes NoIf yes, explain*Has any event occurred in the past 12 months that may have a significantly positive or negative impact practice receipts/ net practice profitability?* Yes NoIf yes, explain*Is the practice owner(s) aware of any upcoming event which may have a significant impact on the future revenue?* Yes NoIf yes, please explain*Do you currently employ an associate(s)?* Yes NoIf yes,*Associate Name/PositionHire DateWill Employee StayBenefitsHours WeekAnnual Salary and/or Commission Percent What benefits do you provide for the staff?*Ex: Pension fund, Health InsuranceDoes your associate have an Employment Agreement?* Yes NoIf yes, do you have a restrictive covenant?* Yes NoIf yes, list miles and years*Have any employed associate(s) or prior partners left the practice in the previous two years and continued practicing in the area?* Yes NoIf yes, did they have an Employment Agreement with a* Restrictive Convenant Non-Solicitation AgreementHow many days did they treat patients in your office?*Do you hire unpaid family members?* Yes NoWhat position do they hold?*What is the estimated market value of their job?*Than the normal salary for their position?*What positions and what is amount of over/under compensation for each*Community FactorsWhat is the population of the community where the principal practice is located?*What is the population of the practice drawing area?*Is area surrounding office location* Urban Growing Stable Affluent Suburban Rural Declining Transient Blue CollarHow would you rate the desirability of your practice location?* Highly Desirable Desirable Average QuestionableAre there any desirable or adverse conditions occurring within the community and/or area's economy?Please describeIs your office located in* Stand alone professional building (no other tenants) Professional building with multiple tenants General office building (mixed healthcare and business) Strip mall shopping center Converted residence Otherselect oneIf other, please decribe*Is your office located on* Freeway access road Two lane street Four lane street Six lane street Otherselect oneIf other, please specify*Is the patient parking* Open lot, free parking Open lot, paid parking Garage, free parking Garage, paid parking Street side parkingselect oneNumber of parking spaces?Proximity of parking spaces?What is the approximate number of dentist(s) whom you consider to be similar to your practice's profile within your immediate geographic region?*List major employers in area?*Ex: Hospitals, grocery storesThe economy in your community is* Diversified Dependent on 1 or 2 industriesPlease provide any relevant detailsList any general comments about our community that may be helpful to this valuation*Facilty FactorsOffice building is* Owned LeasedIf building is owned would you sale?* Yes NoWhat amount would you sale for?If building is owned, would you lease? Yes NoWhat amount would you lease for?*Square footage of building is*Expandable footage*Are you paying rent to yourself or to a separate business entity (if applicable)?* Yes NoIf you lease your office space what is the remaining time on the lease(in months)?*Is there a provision in your lease for renewal?* Yes NoDescribe the terms*Is there an option to purchase?* Yes NoBuilding value to be used*Purchaser mortgage interest rate*Purchaser mortgage term-years*Purchaser monthly payment*Purchaser current monthly rent*Price per square foot*Is there a provision in your lease for assignment?* Yes NoWhat is the present monthly amount of your rent?*Price per square foot?*What does your rent include?*Do you pay any property taxes?* Yes NoIf yes, what amount?*Do you know how much your rent will increase each year for the remaining term of your lease?* Yes NoIf yes, what amount or percent?*Has the building been appraised?* Yes NoIf yes, when?*Appraised price*If building has not been appraised, what would you estimate building price?*Do you know the square foot rental cost for similar office in your area?* Yes NoIf yes, what amount?*Total number of equipped operatories?*Total number plumbed but unequipped operatories?*How many are for left handed operator?*How many are for right handed operator?*Number of doctor treatment rooms?*Number of hygiene treatment rooms?Total number of rooms unplumbed and unequipped?Are doctor treatment rooms equipped with fiber optics?* Yes NoIs your building handicap accessible?* Yes NoList any comments or characteristics about your facility that would be helpful to this valuation:Do you have a computer system?* Yes NoName of software vendor*How many workstations?*Is practice paperless?* Yes NoDo you have any of the following?* Intra Oral Camera(s) Digital X-ray Imaging system Patient education software Panographic x-ray Laser unit CAD-CAM Othercheck all that applyIf other, please specify*Is any equipment presently leased?* Yes NoAverage age of dental equipment*Practice StatisticsNumber of active patients*i.e. ,different individuals who have visited your office for at least one patient visit within the last 18 monthsWhat is the total number of patient records in your practice?*count any patient still remaining in your files for the past 3 yearsWhat type recall system?*What is the total active hygiene recall*18 months actively treated hygiene patientsUpload your fee scheduleReduced fee plansDelta Dental% of usual feeBCBS% of usual feeTennCare% of usual feeMetLife% of usual feeAetna% of usual feeCigna% of usual feeAmeritas% of usual fee Reduced fee plans cont'dHumana% of usual feeGuardian% of usual feeTricare% of usual feeTeamcare% of usual feeHealthSCOPE% of usual feeUnited Concordia% of usual feeFarm Bureau% of usual feeUMR% of usual fee Average number of new patients seen per month for past 2 years*Total patients seen year-to-date*Period covered*i.e., 1/12-4/12What is the percentage of the source from which new patients are derived?*Existing PatientsWebsiteAdvertising (type)New Insurance PlansOther Dental/Medical ProvidersOther Sources must equal 100%Describe internal marketing*Describe external marketing*Who are your practice's major competitors?*What impact have they had on your practice receipts?*Does practice employee a hygienist?* Yes NoIf yes, number of hygiene days per week?*ex: one hygienist working 3 days and another working 4 days equals 7 total daysIf yes, number of hygiene days per year?*If yes, number of weeks worked per year?*Average number of patients seen per day per hygienistHygiene patient visits per yearEstimated 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:*MondayTuesdayWednesdayThursdayFridaySaturday How many hours is the practice open per week?*How many weeks is the dentist 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 DoctorProvided by HygienistTotal % of revenues-Hygiene relatedRestorative(excluding single crowns)Crown & BridgeEndodonticsPediatricsSoft Tissue Management Must equal 100%Percentage Revenue cont'dPeriodonticsOral SurgeryOrthodonticsRemovable ProstheticsFixed ProstheticsImplantsInvisalignTMJ TreatmentProduct SalesOther Must equal 100%Is any of your reported income from any other source than patient treatment from this practice?* Yes NoIf yes, how much in current period?*If yes, how much for last year?*If yes, how much for the previous year?*What is the source of this income?*Percent of income from cash*Percent of patients paying cash*Percent of income from fee for service insurance*Number of patients with fee for service insurance*Percent of practice income from reduced fee plans*Percent of patients with reduced fee plans*Percent practice income from captitation*Percent practice income from medicaid*Percent of patients with medicaid*Which clinical procedures are you referring to area specialist?* Endo Ortho Pedo Oral surgery Perio Implant placement OtherMajority ReferredIf other, please specifyWhich clinical procedures are you referring to area specialist?* Endo Ortho Pedo Oral surgery Perio Implant placement OtherReferred Difficult CasesList sedations used?* Nitrous General Anesthesia IV SedationIs your practice mercury free?* Yes No(no Amalgam)Staff InformationNumber of full-time employees*Number of part-time employees*If this valuation is being done as part of anticipated sale, estimate number of employees who will stay following transitionFinancial InformationHow would you classify your fee scheduled?* Higher than average Average Lower than averageWhat is your collection percentage?*What is your total Accounts Receivable?*insurance balances plus collectionsAs of date*Accounts Receivable-Current*Accounts Receivable-31-60 days*Accounts Receivable-61-90 days*Accounts Receivable-+90 days*What is your patient credit balance?*As of date*Collection CentersGross Collections201820172016 Owner Collections201820172016 Hygienist Collections201820172016 Associate Collections201820172016 Associate Collections201820172016 Associate Collections201820172016 Associate salary in dollars or commission percent*Hygienist salary in dollars or commission percent*3 Years Worth of P&L Statements* Drop files here or Accepted file types: jpg, png, pdf, doc, jpeg.Please estimate the approximate percentages of revenue sources in your practice:100% out of pocket from patientInsurance plans (indemnity)PPOsHMOsMedicaidOther Sources Must equal 100%What is your co-pay at time of service policy?Are you a Delta Premier provider?* Yes NoIf yes, what percentage of your receipts consist of Delta Premier?*Total expense for insurance in current period*Please list below the annual insurance premiums that you pay through your practice as an owner:*Malpractice InsurancePremises/Liability InsuranceWorkmen's CompOffice OverheadStaff Health InsurancePersonal Disability InsuranceLife InsuranceDisability Buy-Out InsuranceOwner Health InsuranceOther Taxes and licenses explanantionTotal expense for taxes*How much of total is for payroll taxes?*How much of total is for staff payroll taxes?*How much of total is for owner payroll taxes?*How much of total is for practice equipment?*How much of total is for real estate taxes?*Pension explanation and 401K combinedTotal expenses for pension plan*How much of total is for staff?*How much of total is for owner?*Benefits ExplanationTotal expense for employee benefits*How much of total is for staff?*How much of total is for owner?*Conformity DataDoes your practice meet OSPHA standards?* Yes NoIf no, why?*Does your practice meet HIPAA standards?* Yes NoIf no, why?*Any practice lawsuits filed in last 10 years?* Yes NoDescribe any health problems which would affect your practice of dentistryAdditional InformationPlease list any additional informationPlease use back of form or attach pages as neededCommentsThis field is for validation purposes and should be left unchanged. 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