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GENERAL
INFORMATION |
| Name:* |
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| Email: |
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| Home
Phone:* |
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| Home
Address:* |
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| City:* |
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| State:* |
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| Zip:* |
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| What
is the purpose of the appraisal:* |
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| If
selling, reason for the sale?: |
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| TYPE
OF PRACTICE* |
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| Type
of Entity:* |
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| If
you are a partnership, how many partners do you have? |
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| City
practice is located in:* |
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| How
long have you been in practice at this location?* |
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OFFICE |
| Do
you own the real estate?* |
Yes
No |
| If
building leased, monthly rental amount: |
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| Total
Square Footage: |
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| Number
of Operatories:* |
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| Do
you have more than one office location:* |
Yes
No |
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PERSONNEL |
| Number
of Employees:* |
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| Number
of Hygienists:* |
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| Number
of hygiene days per week: |
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| Number
of Associates: |
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Number
of Associate hours
per week: |
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| Your
number of clinical hours per week:* |
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GROSS
RECEIPTS |
| Most
recent annual practice gross range:* |
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PRACTICE
INFORMATION |
| Percent
of Managed Care: |
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| Percent
of Medicaid: |
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| Approximate
total number of active patients: |
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| Do
you have a computer system?* |
Yes
No |
| What
software program do you use? |
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