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SELLERS
- Dental Practice Appraisals
- Additional Services
BUYERS
DSO CONSULTING
About Us
- Services
- Contact Us
Resources
VIEW LISTINGS

Buyer Profile Info

Buyer Profile Info

Please complete the following profile so we can better understand your preferences for practice opportunities. We can also notify you of practice opportunities as they become available.

Buyer Profile

Please complete the following profile so we can better understand your preferences for practice opportunities. We can also notify you of practice opportunities as they become available.

"*" indicates required fields

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General

First Name*

Last Name*

Email*

Date of Birth

Month

Date

Year

Are you a US citizen?*

Yes

No

What is your current INS status?

Home Phone Number

Will your Spouse be the primary contact?

Yes

No

Spouse's Full Name

Spouse's Email

Spouse's Mobile Phone

What is your current career status?

How many years have you been in the above career status?

Dental School Attended

Graduation Year

State of Dental License

License Number

Residency/Graduate School Attended

Graduation Year

Degree

Practice Criteria

What Regions in Texas are of most interest to you? (Please check all that apply.)*

Austin and Hill Country

Central Texas

Dallas and Suburbs

East Texas

El Paso Area

Fort Worth and Suburbs

Houston and Suburbs

Panhandle

San Antonio Area

South Texas

West Texas

What practice types are you interested in? (Please check all that apply.)*

General

Endodontic

Oral Surgery

Orthodontic

Pediatric

Periodontal

Prosthodontic

What transition types are you interested in? (Please check all that apply.)

Practice for Sale

Practice Merger

Associateship

Partnership

Facility for Sale

Real Estate for Sale

What is the ideal date for this transition?

MM slash DD slash YYYY

What delivery system do you prefer?

What is the ideal number of operatories you want in the facility?

What is the ideal amount of annual collections you want for the practice?

What is your desired annual income?

What is your preference for patient payment type?

Would you be willing and able to relocate?

Yes

No

What is the furthest commute you would consider?

First Preference of City for Practice

Second Preference of City for Practice

Third Preference of City for Practice

Please indicate any other preferences or criteria you have in selecting the ideal practice opportunity.

Background Questionnaire

Do you require any reasonable accommodations in order to perform the essential functions of the position for which you are considering?

Yes

No

Please explain what accommodations you require:

Do you currently have any infectious diseases that ethically you feel should be disclosed to potential patients?

Yes

No

Please explain:

Have you been the subject of any disciplinary proceedings by the State Dental Board?

Yes

No

If Yes, please explain:

Are there any unsatisfied judgments against you or any business you have owned?

Yes

No

If Yes, please explain:

Have you ever filed for bankruptcy?

Yes

No

If Yes, please explain:

Have you ever been found guilty, entered a plea of "no contest", or been a party to a consent degree with regard to any of the following? (check each box that applies)

Malpractice Claim

Crime involving moral turpitude

Criminal or civil litigation involving substance abuse

Charge of Fraud or Tax-Avoidance with regard to any Federal or State taxes

If yes, please explain: (Malpractice claim)

If yes, please explain: (Crime involving moral turpitude)

If yes, please explains: (Criminal or civil litigation involving substance abuse)

If Yes, please explain: (Charge of Fraud or Tax-Avoidance with regard to any Federal or State taxes)

Professional Advisers

Are you working with another Broker?

Yes

No

What is the Broker's name?

Which lenders have you already contacted about financing?

Do you have an Accountant?

Yes

No

What is the Accountant's name(s)?

Do you have an Attorney?

Yes

No

What is the Attorney's name(s)?

Do you have an Insurance Agent for Life & Disability?

Yes

No

What is the Insurance Agent's name(s)?

Electronic Signature

Full Legal Name*

By checking the Electronic Signature box, I agree that to the best of my knowledge, all of the information provided is accurate and correct. I also agree that such action is an electronic substitute for my signature on this form. I also acknowledge that the information provided in this form is intended to be and will be disclosed to persons (including corporations, partnerships, firms, lenders and other individuals) for the purposes contemplated and that ADS Watson, Brown & Associates shall have no liability for any claims, demands or action arising in connection herewith.*

Electronic Signature

Email Notifications

Please email when new practice opportunities become available.

Please enroll me for the free e-newsletter, ADS Insider.

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