Doctor Type *—Please choose an option— Dentist Optometrist Physician Veterinarian Behavioral Health Nurse Non-Doctor Other
Doctor Sub Type *—Please choose an option— General Endodontist Multi-Specialty Oral and Maxillofacial Surgery Orthodontist Pediatric Periodontist Prosthodontist Other
Doctor Sub Type *—Please choose an option— Allergy & Immunology Chiropractor Dermatology Family Practice / Primary Care Gastroenterologist General Geriatric Medical Spa OB/GYN Oncology Otolaryngology Pain Management Pathology Pediatric Podiatrist Psychologist Pulmonary Rheumatology Sports Medicine Surgery - Cosmetic Surgery - MOHS Micrographic Surgery - OB/GYN Surgery - OMS Surgery - Orthopedic Surgery - Orthopedic (Foot) Surgery - Orthopedic (Hand) Surgery - Orthopedic (Spine) Surgery - Plastic Surgery - Plastic (Facial) Surgery - Plastic & Reconstructive Urgent Care Urology Other
Doctor Sub Type *—Please choose an option— All Animals Large Animals Small Animals Other
Doctor Sub Type *—Please choose an option— Medical Spa Dental Lab Other
Birth Year—Please choose an option— 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930
EDUCATION
School Attended—Please choose an option— AL - University of Alabama at Birmingham AZ - Arizona School of Dentistry and Oral Health AZ - A.T. Still University AZ - Midwestern University Arizona CA - Alameda Health System - Highland Hospital CA - University of California (Campus Unknown) CA - Loma Linda CA - UCLA CA - UCSF CA - USC CA - University of the Pacific CA - Western University of Health Sciences CO - University of Colorado CT - Yale School of Medicine CT - University of Connecticut DC - George Washington University DC - Georgetown DC - Howard University FL - Jacksonville University School of Orthodontics FL - University of Florida (AEGD) FL - Lake Erie College of Osteopathic Medicine FL - Nova Southeastern University FL - University of Florida FL - University of Miami GA - Augusta University GA - Emory IA - University of Iowa IL - Loyola Chicago IL - Loyola IL - Midwestern University Illinois IL - Northwestern University IL - Southern Illinois University IL - University of Illinois at Chicago IN - Indiana University International - Foreign KY - Louisville KY - University of Kentucky LA - Loyola New Orleans LA - LSU LA - Tulane MA - Boston University MA - Harvard MA - Tufts MD - University of Maryland at Baltimore ME - University of New England MI - University of Detroit Mercy MI - University of Michigan MN - University of Minnesota MO - St. Louis University MO - UMKC MO - Washington University (St. Louis) MS - University of Mississippi NC - Womack Army Medical Center NC - East Carolina University NC - University of North Carolina NE - Creighton University NE - University of Nebraska NJ - University of Medicine and Dentistry of New Jersey NJ - Fairleigh-Dickinson University NJ - Rutgers NM - University of New Mexico NV - Roseman University NV - UNLV NY - Albert Einstein College of Medicine NY - SUNY NY - Touro College of Dental Medicine NY - Columbia University NY - Lutheran Medical Center NY - New York University NY - SUNY Buffalo NY - SUNY Stony Brook NY - University of Rochester School of Medicine and Dentistry OH - MetroHealth Medical Center OH - Case Western Reserve University OH - Ohio State University OK - Oral Roberts University OK - University of Oklahoma OR - North Pacific College (Portland, OR) OR - Oregon Health and Science University PA - Seton Hill University Center for Orthodontics PA - Temple University PA - University of Pennsylvania PA - University of Pittsburgh PR - Puerto Rico SC - Medical University of South Carolina TN - Meharry TN - University of Tennessee TN - Vanderbilt TX - Texas Tech University TX - Texas A&M University Baylor College of Dentistry TX - UT Houston TX - UT San Antonio UT - Weber State University UT - University of Utah VA - Virginia Commonwealth University WA - University of Washington WI - Marquette University WV - West Virginia University Year Graduated—Please choose an option— 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950
WORK HISTORY
Current Career Stage *—Please choose an option— Student/Resident Part Time Associate Full Time Associate Not Currently Practicing Single Practice Owner Multiple Practice Owner Partner in a Group Practice Retired Other Equipment Dexterity—Please choose an option— Right Left
LENDING
PRACTICE CHARACTERISTICS
When Are You Looking to Purchase a Practice?—Please choose an option— Today 0 - 6 months 6 - 12 months 12 - 18 months 18 - 24 months 2 - 3 years 3 - 5 years 5 years + Where Are You Looking to Purchase a Practice?
Minimum Number of Operatories/Lanes?—Please choose an option— Any 3 4 5 6 7-10 11+ Annual Practice Revenue Range?—Please choose an option— 0 - $250,000 $250,000 - $500,000 $500,000 - $750,000 $750,000 - $1,000,000 $1,000,000 - $1,500,000 $1,500,000 - $2,000,000 $2,000,000+ What Is The Maximum Level of Medicaid Reimbursement Acceptable?—Please choose an option— None Any 10% 20% 30% 40% 50% 60% 70% 80% 90% Please Provide any Additional Information That May Assist Us In Locating Your Ideal Practice
COMPANY INFORMATION
We Are Interested In Purchasing The Following Type of Practice(s) *
Number of Practices Owned—Please choose an option— 0 1 2-4 5-9 10-19 20-49 50-99 100-249 250-499 500-999 1,000+
COMPANY GOALS
We Are Looking To Grow By *—Please choose an option— Acquiring Single Practices Acquiring Portfolios of Practices DENOVO / Start Up Locations The Following Best Describes Our Typical Acquisition Structure *—Please choose an option— Partnership with current practice owner We purchase full practice and re-brand We purchase full practice and retain current branding
ACQUISITION CRITERIA
When Are You Looking to Purchase a Practice?—Please choose an option— Today 0 - 6 months 6 - 12 months 12 - 18 months 18 - 24 months 2 - 3 years 3 - 5 years 5 years + Where Are You Looking to Purchase a Practice? Minimum Annual Practice Revenue Range?—Please choose an option— 0 - $250,000 $250,000 - $500,000 $500,000 - $750,000 $750,000 - $1,000,000 $1,000,000 - $1,500,000 $1,500,000 - $2,000,000 $2,000,000+ Minimum EBITDA per Practice?—Please choose an option— 0 - $250,000 $250,000 - $500,000 $500,000 - $1,000,000 $1,000,000+ Minimum Number of Operatories/Lanes?—Please choose an option— Any 3 4 5 6 7-10 11+ What Is The Maximum Level of Medicaid Reimbursement Acceptable?—Please choose an option— None Any 10% 20% 30% 40% 50% 60% 70% 80% 90% Please Provide any Additional Information That May Assist Us In Locating Your Ideal Practice
