Appraisal Request Form – Apex Dental Partners

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Contact Information

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Preferred Method of Contact *

Phone
Email

Practice Information

Practice Name *

Practice Address *

Address Line 1

Address Line 2

City

State

Zip Code

Year Established *

Number of Operatories *

Square Feet

Estimated Revenue *

Do you have partner(s) or associate(s)?

Yes
No

How many partners or associates?

Payor Mix (select all that apply) *

FFS
PPO
HMO
Medicaid

What percent is Fee For Service?

What percent is PPO?

What percent is HMO?

What percent is Medicaid?

Condition of Equipment *

New/Modern
Good/Dated
Needs Updating

Type of X-Ray *

Digital
Conventional

Patient Records *

Digital
Paper

Ability to commit to staying 2+ years? *

Yes
No
Maybe

100% completed