

	California Practice Sales, Inc 326 W. Katella Avenue Suite 4-G Orange, California 92867 (ph) 866-377-0446 (fax) 714-771-1346 click here for directions and a map to our office

John Knipf – President, California Practice Sales, Inc.

Seller Questionnaire

If you are interested in adding your dental practice to our listings in Southern California, the first step would be to have California Practice Sales prepare a confidential pricing model. This model is then used to determine if we can work together as a team to assist you in the sale of your dental practice.

There is no cost or obligation to you if we prepare a model, but certain information is necessary. All information and documentation provided to California Practice Sales is held in the strictest confidence.

Before we can prepare a pricing model and add your dental practice to our listings in Southern California, we will need for you to provide the following information. Once submitted, you will receive a personal phone call from Mr. Knipf to discuss your needs and concerns.

* All indicated fields must be completed.

*Address Me As:
Practice address:
Practice city:
Practice state:
Practice zip code:
A confidential phone number where we may reach you:
*A confidential email address where we may reach you:

Are you a GP or a specialist?

How long have you been in business at the current location?
How many square feet in your current practice location?
How many treatment rooms do you currently have?
How long is left on your current lease?
What is your monthly lease payment?
Do you have any options?		Yes No
If yes, how long?

Collections year to date:
Collections for the previous year:
How many patients do you currently see a day?
How many new patients do you see a month?
What percentage of your practice income is attributed to cash?
What percentage of your practice income is attributed to insurance?
What percentage of your practice income is attributed to Medi-Cal?
What percentage of your practice income is attributed to Capitation?

How many days do you currently work a week?
How many days of hygiene do you have?
Do you have a hygienist?		Yes No
Do you have any associates?		Yes No
How many staff members are currently employed in the office?

If you are interested in adding your dental practice to our listings in Southern California, California Practice Sales would be happy to prepare a confidential pricing model for you. Simply fill out the seller questionnaire on our website, and we will contact you as soon as possible.

The CPS privacy policy is very simple: We will not share your private information with anybody, ever, absent your permission or a court proceeding which compels us to produce such information. Period.