Seller Registration Form

Thinking about selling your practice? The information you enter below is deemed private and CONFIDENTIAL; Leadership by Design LLC uses this information for the sole purpose of evaluating and assessing your needs. Thank you again for your interest and we look forward to helping you make a smooth transition into your next life chapter. Once completed, we will contact you for a confidential conversation.

Confidential Seller Registration Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Practice Type *

Purpose/Interest *

Practice Address *

Line 1

Line 2

City

State

Zip Code

Country

Own or lease your space? *

Number of years at current location *

Describe location (growing, stable, stagnant)? *

Approximate square footage of practice *

Number of operatories/treatment rooms *

Number of staff (full and part-time): *

Estimated number of Active Patients (18 months) *

Estimated collections (prior year): *

Average number of days you are currently working *

Name of dental software: *

Please list any updated equipment *

Best time of day to contact you: *

Submit

Confidential Seller Registration Form

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