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

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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%

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Percentage Revenue cont'd
Periodontics Oral Surgery Orthodontics Removable Prosthetics Implants Invisalign Product Sales Other

Must equal 100%

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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

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

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Associate Name	Hire Date	Hours Week	Monthly Production

General Information

Name	% of Ownership	Name	% of Ownership

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