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 DentistryDoes 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 NoWill seller's ongoing employment be a condition of sale?* Yes NoIf yes, Seller's required number of clinical hours per week after sale?*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 historyHow 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 NoHas 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, please explain*Is the practice owner(s) aware of any upcoming event which may have a significant impact on the future revenue?* Yes NoDo you currently employ an associate(s)?* Yes NoIf yes,*Associate NameHire DateHours WeekMonthly Production Does 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?*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 oneWhat 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 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*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 a provision in your lease for assignment?* Yes NoWhat is the present monthly amount of your rent?*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?*Do you know the square foot rental cost for similar office in your area?* Yes NoIf 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 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 is the total active hygiene recall*18 months actively treated hygiene patientsUpload your fee scheduleAverage 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%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 daysAverage number of patients seen per day per hgienistEstimated 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 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 DoctorProvided by HygienistTotal % of revenues-Hygiene relatedRestorative(excluding single crowns)Crown & BridgeEndodonticsPediatrics Must equal 100%Percentage Revenue cont'dPeriodonticsOral SurgeryOrthodonticsRemovable ProstheticsImplantsInvisalignProduct SalesOther Must equal 100%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 CasesStaff 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 transitionHave any employed hygienists left the practice in the previous two years and continued practicing in the area?* Yes NoIf yes, how many days a week did they treat patients in your office?*Financial InformationHow would you classify your fee scheduled?* Higher than average Average Lower than averageWhat is your total Accounts Receivable?*insurance balances plus collectionsAs of date*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?*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 Additional InformationPlease list any additional informationPlease use back of form or attach pages as neededCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
