Appraisal Request Form Wondering what your practice is worth? Fill out this form! First Name* Last Name* Phone* Email* 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 Equipment Condition New/Modern Good/Dated Needs Updating Type of X-Ray* Digital Conventional Patient Records* Digital Paper 2 Year Commitment * Yes No Maybe Submit
