Seller Registration Form

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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? *

Approximate square footage of practice *

Number of years at current location *

Describe location (growing, stable, stagnant)? *

Practice hours: *

Number of operatories/treatment rooms *

Charts: *

Check any/all team members at your practice: *

Associate Hygiene 1 Hygiene 2 Dental Assistant 1 Dental Assistant 2 Office Manager Insurance Coordinator Other

Estimated number of new patients/month: *

Estimated number of Active Patients (24 months) *

We are happy to assist you with this "Last visit date" report.

Check any/all services you refer out *

Ortho Endo Oral Surgery Oral Appliances (Sleep apnea, etc.) Other None

Estimated annual collections (prior year): *

Practice management software: *

Patient communication software: *

Approximate age of computer system: *

Please list any equipment purchased in the last 7 years: *

Best time of day to contact you: *

Submit

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FOR PRACTICES
JOB SEEKERS
- Dentist Profile Form
- Staff Profile Form
CLASSIFIEDS
- Practices for Sale
- Dental Jobs
ABOUT
CONTACT
BLOG