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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

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If sale, will seller continue with practice after sale?*
- Yes
- No
Will seller's ongoing employment be a condition of sale?*
- Yes
- No
If yes, Seller's required number of clinical hours per week after sale?*
Does practice owner(s) operate any satellite/additional offices?*
- Yes
- No
If yes, please identify location(s)*
Do offices file seperate tax returns?*
- Yes
- No
How far is/are satellite office(s) located from primary office?*
Practice History
How was practice aquired?*
- Started by present owner
- Purchased
Date practice was started or acquired?*
MM
DD
YYYY
If 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
- No
If 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 history
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
- No
Has any event occurred in the past 12 months that may have a significantly positive or negative impact practice receipts/ net practice profitability?*
- Yes
- No
If yes, please explain*
Is the practice owner(s) aware of any upcoming event which may have a significant impact on the future revenue?*
- Yes
- No

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Do you currently employ an associate(s)?*
- Yes
- No
If yes,*
Associate Name Hire Date Hours Week Monthly Production
Does your associate have an Employment Agreement?*
- Yes
- No
If yes, do you have a restrictive covenant?*
- Yes
- No
If 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
- No
If yes, did they have an Employment Agreement with a*
- Restrictive Convenant
- Non-Solicitation Agreement
How many days did they treat patients in your office?*
Community Factors
What 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 Collar
How would you rate the desirability of your practice location?*
- Highly Desirable
- Desirable
- Average
- Questionable
Are there any desirable or adverse conditions occurring within the community and/or area's economy?
Please describe
Is 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
- Other
select one
If other, please decribe*

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Is your office located on*
- Freeway access road
- Two lane street
- Four lane street
- Six lane street
- Other
select one
If other, please specify*
Is the patient parking*
- Open lot, free parking
- Open lot, paid parking
- Garage, free parking
- Garage, paid parking
- Street side parking
select one
What is the approximate number of dentist(s) whom you consider to be similar to your practice's profile within your immediate geographic region?*
The economy in your community is*
- Diversified
- Dependent on 1 or 2 industries
Please provide any relevant details
List any general comments about our community that may be helpful to this valuation*
Facilty Factors
Office building is*
- Owned
- Leased
If building is owned would you sale?*
- Yes
- No
What amount would you sale for?
If building is owned, would you lease?
- Yes
- No
What amount would you lease for?*
Square footage of building is*
Are you paying rent to yourself or to a separate business entity (if applicable)?*
- Yes
- No
If 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
- No
Describe the terms*
Is there a provision in your lease for assignment?*
- Yes
- No
What is the present monthly amount of your rent?*
What does your rent include?*
Do you pay any property taxes?*
- Yes
- No
If yes, what amount?*
Do you know how much your rent will increase each year for the remaining term of your lease?*
- Yes
- No
If yes, what amount or percent?*

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Do you know the square foot rental cost for similar office in your area?*
- Yes
- No
If yes, what amount?*
How many treatment rooms in total?*
How many are for left handed operator?*
How many are for right handed operator?*
Number of doctor treatment rooms?*
Number of hygiene treatment rooms?
How many rooms are finished but not equipped?
Are doctor treatment rooms equipped with fiber optics?*
- Yes
- No
Is your building handicap accessible?*
- Yes
- No
List any comments or characteristics about your facility that would be helpful to this valuation:
Do you have a computer system?*
- Yes
- No
Name of software vendor*
How many workstations?*
Is practice paperless?*
- Yes
- No
Do 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
- Other
check all that apply
If other, please specify*
Is any equipment presently leased?*
- Yes
- No
Average age of dental equipment*
Practice Statistics
Number of active patients*
i.e. ,different individuals who have visited your office for at least one patient visit within the last 18 months
What is the total number of patient records in your practice?*
count any patient still remaining in your files for the past 3 years
What is the total active hygiene recall*
18 months actively treated hygiene patients
Upload your fee schedule

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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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Which clinical procedures are you referring to area specialist?*
- Endo
- Ortho
- Pedo
- Oral surgery
- Perio
- Implant placement
- Other
Majority Referred
If other, please specify
Which clinical procedures are you referring to area specialist?*
- Endo
- Ortho
- Pedo
- Oral surgery
- Perio
- Implant placement
- Other
Referred Difficult Cases
Staff Information
Number 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 transition
Have any employed hygienists left the practice in the previous two years and continued practicing in the area?*
- Yes
- No
If yes, how many days a week did they treat patients in your office?*
Financial Information
How would you classify your fee scheduled?*
- Higher than average
- Average
- Lower than average
What is your total Accounts Receivable?*
insurance balances plus collections
As of date*
3 Years Worth of P&L Statements*
Drop files here or
Accepted file types: jpg, png, pdf, doc, jpeg.

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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
Phone
This field is for validation purposes and should be left unchanged.

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Have Questions?

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

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If you are ready to take your business or your practice to the next level. Contact Bryant Consultants. We are ready to offer a plan to take you and your office to the top. Call Today.

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4889 Eagle Pointe Dr
info@bryantconsultants.com

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