LEARN THE TRUE VALUE OF YOUR DENTAL PRACTICE LEARN THE TRUE VALUE OF YOUR DENTAL PRACTICE Appraisal Request Form Wondering what your practice is worth? Fill out this form! First Name* Last Name* Phone* Email* Mailing Address* City State Option 1 Option 2 Option 3 Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zipcode Preferred Contact Method* Text Email Phone Practice Name* Practice Address 1 Practice Address 2 Practice City Practice State/Province Practice Postal Code Year Established* Number of Operatories* Square Feet* Estimated Revenue* Less than $500,000 $500,000 - $750,000 $750,000 - $1,000,000 $1,000,000 - $1,500,000 Greater than $1,500,000 Do you have partner(s) or associate(s)?* How many partners or associates do you have? 1 2 3 More Payor Mix* FFS PPO HMO Medicaid What percent is Fee For Service? What percent is PPO? What percent is HMO? What percent is Medicaid? Equipment Condition 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 Submit
