Name:

Private Mailing Address:

Private Telephone No.: ( ) Private Fax No.: ( )

Personal E-Mail Address:

Practice Address

Year Graduated / University:

I am a: General Dentist Specialist ( - type)

Office:
Total Square Footage    Number of operatories (equiped)
Do you Own building? (Y/N)    If so, what %
Do you have an Accurate set of Floor Plans? (Y/N)   

Personnel:
   # of Associates?  Full-time?    Part-time?
   # of Hygienists?   Full-time?    Part-time?   

Partners:
  Do you have partners? (Y/N)   How many?
  If so, are they:  Cost Share?   or Equity?   

Financial:
  Are you incorporated? (Y/N)  
  Is there a Holding/Management company?(Y/N)
  How many sets of Financial Statements do you have?   

Gross:
Most recent Annual Gross Revenue (of the entire practice).$  

Scheduling:
What would be the best day, when the practice is or can be closed, for us to visit the office?  

Notes:
 Is there anything unique or particular that you'd like to tell us about your practice?