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Sherri Merritt
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Menu
Home
About
Meet Our Team
Hollie Bryant
Sherri Merritt
Tony Myers
Tyra Kendall
Services
Dental Consulting
Jump Start Training
In Office Consulting
Off-Site Coaching
Dental Practice Reboot
Phone Skills Training
Team Training
Leadership Training
Dental Assistant Clinical Training
Ask the Coach
Team Retreats for Dental Practices
Dental Practice Transitions
Tony Myers
Practice Transitions
How to find the Right Dental Practice Transitions Consultant
FAQs about Dental Practice Transition
Practice Transition Questionnaire
Marketing Services
Website Design
Search Engine Optimization
Social Media
Graphic Design
Paid Search
Why Internet Marketing?
Seminars/Events
Blue Collar Business Consulting
Small Business Reboot
Am I Ready to Hire a Small Business Coach?
How to Hire a Small Business Coach
What is a Small Business Coach?
Reviews/Our Work
Design Gallery
Testimonials and Reviews
The Latest
Resources
Community Partners
Client Tracking Form
Sign Off Form
Team Member Questionnaire
Owner’s Questionnaire
DSO Owner’s Questionnaire
Employee Questionnaire
Logo Design Questionnaire
Media
Contact
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
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
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
*
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?
*
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
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%
Percentage Revenue cont'd
Periodontics
Oral Surgery
Orthodontics
Removable Prosthetics
Implants
Invisalign
Product Sales
Other
Must equal 100%
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.
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
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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