Buyers We want to make sure we know exactly what type of practice opportunity you are looking for! Please complete this form & we will be in touch! DENTIST NAME:(Required) DEGREE:(Required) DDS DMD SPECIALTY:(Required) ADDRESS:(Required) Practice Name Address City State / Province / Region ZIP / Postal Code CELL:(Required)EMAIL:(Required) HOW WOULD YOU LIKE TO BE CONTACTED?(Required) CELL EMAIL WHERE DID YOU GO TO UNDERGRAD?(Required) YEAR GRADUATED:(Required) NAME OF DENTAL SCHOOL:(Required) YEAR GRADUATED:(Required) ANY ADDITIONAL EDUCATION OR TRAINING?(Required) ARE YOU CURRENTLY WORKING WITH A BROKER?(Required) YES NO IF YES, ARE YOU UNDER AN EXCLUSIVITY AGREEMENT WITH THEM?(Required) YES NO WHAT IS THE NAME OF THE BROKER?(Required) DO YOU CURRENTLY OWN A PRACTICE:(Required) YES NO IF YES, WHAT IS THE FOLLOWING:NAME:(Required) ADDRESS:(Required) Street Address City State / Province / Region ZIP / Postal Code WHAT ARE THE NAMES OF THE PRACTICES, ADDRESS(S), CO-OWNERS IF ANY:1. NAME OF PRACTICE CO-OWNER: YES NO Co-Owner Name: Address: 2. NAME OF PRACTICE CO-OWNER: YES NO Co Owner Name: Address: 3. NAME OF PRACTICE CO-OWNER: YES NO Co Owner Name: Address: BUYER PREFERENCESLOCATION: COUNTY, SUBURB, CITY, REGION OR STATE? CHART SALE FOR AN EXISTING PRACTICE?(Required) YES NO IF YES, WHERE IS THE PRACTICE LOCATED THAT YOU ARE DESIRING TO EXPAND WITH CHARTS?(Required) PRACTICE ANNUAL COLLECTIONS DESIRED:(Required) UNDER $500,000 $500,000 TO $750,000 $750,000 TO 1 ML $1 MILLION TO $1.5 ML $1.5 ML TO $2 ML $2 ML TO $3 ML $3 ML and above TYPE OF PRACTICE(Required) Fee for Service PPO Medicaid HMO # OF OPERATORIES:(Required) 1-3 4-6 7+ ARE YOU(Required) A LEFTY OR A RIGHTY DO YOU PREFER:(Required) REAR OR SIDE DELIVERY ANY TYPE OF TECHNOLOGY DESIRED?(Required) CEREC CONE BEAM LASERS SCANNERS ADDITIONAL TECHNOLOGY DESIRED:(Required) HAVE YOU BEEN PRE-APPROVED:(Required) YES No WHO IS YOUR BANKER?(Required) WOULD YOU BE INTERESTED IN RECEIVING COMPETITVE QUOTES?(Required) YES No WHAT IS YOUR TIMELINE FOR PURCHASING:(Required) 3 MONTHS 6-9 MONTHS 12-18 MONTHS 24 MONTHS + IF YES, FOR WHAT AMOUNT?(Required) OTHER DESIRED PREFERENCES:(Required) CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
