Practice Transition Questionnaire

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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

Associate Name	Hire Date	Hours Week	Monthly Production

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

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

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

Periodontics	Oral Surgery	Orthodontics	Removable Prosthetics	Implants	Invisalign	Product Sales	Other

General Information

Name	% of Ownership	Name	% of Ownership

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

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