Selling Your Dental Practice Survey Selling Your Practice Online Selling Your Practice Form Name of Practice?* First Website URL? Doctors Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Practice Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone Number*Contact Email* Enter Email Confirm Email Best Time to Contact You?*Dental school attended?*Graduated what year?*Names of study clubs:*Reason for practice analysis?*What are your post sale plans?Do you own any other practices in the area? If so, explain*When would you like to retire?*Are you looking to: (Hold Ctrl/Cmd to select multiple items)*Sell?Bring on an associate/partner?Merge with another office?Other Reason? Please explain belowPlease Explain Here:Do you want to work in the practice after the sale?*YesNoDo you own the building your office is in?*YesNoWhat practice software do you use? (Hold Ctrl/Cmd to select multiple items)*Digital XrayPanoCTLaserCerecOtherWhat services do you refer out currently? (List all that apply)*Days worked per week?*Number of hygiene days per week?*Number of ops total?*Number Doctor ops total?*Number Hygiene ops total?*Average Production per month?*Average Collection per month?*Average number of new patients per month?EmailThis field is for validation purposes and should be left unchanged.
