| POTENTIAL SELLER'S APPROXIMATE PRACTICE VALUE |
Please provide the following information to us:
(You can also print out a PDF of this form here or a Word 2003 version of
this form here. Then fax the form to us at 714-398-8808)
this form here. Then fax the form to us at 714-398-8808)
Your name: _____________________________________________
Your address: ___________________________________________
___________________________________________
Confidential telephone number: _____________________________
Type of practice: _________________________________________
(Indicate general or specify specialty type)
Collections, this year to date: _______________________________
As of date: _____________________________________________
Collections for last year, as shown on your tax return: ____________
Insurance composition of practice:
Private: ____% Indemnity: ____% PPO: ____%
HMO: ____% Medi-Cal: ____%
How long have you been practicing in this location? _____________
Number of operatories: ___________________________________
Professional building or commercial center? ___________________
Square footage of practice: _________ Lease payment: ________
Number of years remaining on lease/options: __________________
Number of days you work per week: _________________________
Number of employees, in what positions: ______________________
Bette Robin, DDS, JD 877 DrRobin
SELECT PRACTICE SERVICES, INC. / DENTAL PRACTICE SALES
SELECT PRACTICE SERVICES, INC. / DENTAL PRACTICE SALES
DrRobin@BetteRobin.com
17482 Irvine Blvd., Ste. E
Tustin, CA 92780
Tustin, CA 92780
Tele:
Fax:
Fax:
877 DrRobin
714-421-4407
714-398-8808
714-421-4407
714-398-8808
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