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 714-333-4394)

Your name:  _____________________________________________

Your address:  ___________________________________________

___________________________________________

Your email:  _____________________________________________

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.                                                           714-421-4407
Dentist, Attorney, Real Estate Broker                                                                                                                            
17482 Irvine Blvd., Ste. E
Tustin, CA  92780
DrRobin@BetteRobin.com
877-DrRobin
714-421-4407
714-333-4394
Call:

Fax:
SELECT PRACTICE SERVICES, INC.