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 to schedule an appointment with Dr Schroeder.

Seller Registration Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Website *

Specialty *

When Would You Like to Sell Your Practice? *

Primary Office Address *

Line 1

Line 2

City

State

Zip Code

Country

How Many Years at Current Location? *

How Would You Describe Location (growing, stable, stagnant)? *

Name (s) of Partners or Associates: *

Average Number Days/Week You Are Currently Working: *

Would You Consider Working Part-time Post-sale? How Many Hours/Week? *

Type of Facility: *

Stand-alone Building Building with other Tenants Other

What is Square Footage of Your Practice? *

Do You Own or Lease Office Space? *

Number of Clinical Operatories: *

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

Estimated number of Active Patients (seen within past 18 months): *

Estimated Total Number of Patient Records? *

Average Number of Clinical Visits /Month: *

Average Hygiene Appointments/ Month: *

Name of Your Dental Software Provider: *

List Participating Insurance Networks: *

List Equipment (digital x-ray, etc): *

Average Number New Patients /Month: *

What else would you like to let us know about your practice? *

Submit

Seller Registration Form

Services

Support

(804) 897.5900