Dental Valuation Step 1 of 9 11% Valuation Date(Required) MM slash DD slash YYYY Practice Name(Required)Website:Practice Phone Number:(Required)Practice Email:(Required) Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Tax Entity:(Required) LLC PLLC PC S-Corp C-Corp Sole Proprietor Partnership Other Practice Type:(Required) General Dentistry Pediatric Orthodontic Periodontic Endodontic Oral Surgery Prosthodontic Multi-specialty Other (text) Other Business Type:(Required) Solo Group (2+ doctors) Hygiene Only Other Form of Sale Assumption(Required) Asset sale (assume assets + goodwill; excludes stock) Equity/stock sale (assume entity shares) Unknown — use Asset Sale assumption Other How are you selling your practice?(Required) 100% practice sale Associate buy-in / buy-out Partner dispute Estate / tax planning Divorce / litigation Financing / bank requirement Other If Partial Sale or Buy-In, % to be valued(Required)Included in the Practice Value (Only select what you are selling) Equipment & furnishings used in operations Charts/records & practice goodwill Phone numbers, website/domain, brand assets Office supplies on hand (consumable inventory) Clinical Supplies/Inventory Cash in bank Accounts receivable (AR) Real estate/building/condo unit Personal vehicles/personal assets Investments/other non-operating assets Select AllOther Assets Not Listed(Required)seller stays X months for transition; non-compete; normal staffingSeller Transition Assumption Seller leaves at closing (0 months) Seller stays 3 months Seller stays 6 months Seller stays 12 months Unknown Other If seller stays: Clinical schedule during transition(Required) 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week Unknown Other What do you believe your practice should be sold for and why?(Required)When would you like this practice sold? (i.e. 3-6 months, 1 year etc)(Required) Owner and Partner/s Information:Provider/s: (Enter primary owner first) Name:(Required)Email:(Required)Cell Phone:(Required)% of ownership:(Required)What year did this provider start working for the company?(Required)What year did this provider become a partner/owner(Required)Copy of Professional License(Required) Drop files here or Select files Max. file size: 50 MB. This Partners Production By Month For The Last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. This Partners Collections By Month For The Last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Facility:Ownership/Lease(Required) Owned by doctor personally Owns condo/unit Owned by separate real estate entity (LLC, etc.) Leases from third-party landlord Sublease / shared space Lease with option to purchase (rent-to-own) Other If leased: Current monthly base rent(Required)Total Square Footage:(Required)Year facility was built(Required)Annual Property Taxes:(Required)For condo/unit, HOA fees:(Required)If leased: Monthly CAM/NNN(Required) None / Included in rent Unknown Other Lease term remaining(Required) < 1 year 1–2 years 2–5 years 5+ years Unknown Other Lease/Sublease Terms, amendments or optionsMax. file size: 50 MB. Interior Pictures of Facility(Required) Drop files here or Select files Max. file size: 50 MB. Break Room, Waiting Room, Halls, Doctors Office, Lab, SterilizationExterior Pictures of Facility(Required) Drop files here or Select files Max. file size: 50 MB. Clinical Time and UseTotal hygiene hours per week:(Required)Total Doctor Treatment Hours Per Week:(Required)Total Operatories: (including ones that are plumbed but in use)(Required)How many of those operatories are ready for care? (plumped, equipment, patient ready)(Required)How many are used for Hygiene?(Required)How many are used for Doctor?(Required)Swing/Overflow Op(Required)Is this practice chartless?(Required) Completely Paperless (with the exception of paper routers) Partially Paperless Other If not completely chartless, what is still being used in paper charts?(Required)Operatory & EquipmentOp 1 Please Only Select What Is Dedicated To This Op and are not shared. There is a section after the operatory listings where equipment such as x-ray sensors, intraoral camera's, laser's etc Used for Doctor Used for Hygiene Sink Shared Sink Piezo Laser Monitor Second Monitor Cavitron Computer Prophy Jet Lead Apron Curing Light Tablet or Ipad Overhead light Intraoral Camera Water Bottle System Plumbed Water System High Speed Handpiece Low Speed Handpiece Surgical Handpiece Transillumination Device Nitrous (fixed/plumbed) Fixed Xray Unit (Dedicated to this op only) Shared Xray Unit between operatories Select AllOther Equipment Not ListedPictures of Operatory(Required) Drop files here or Select files Max. file size: 50 MB. Other Equipment CBCT / Cone Beam CT Digital impression scanner (intraoral scanner) Panoramic X-ray unit Cephalometric add-on Transillumination caries detection Handheld X-Ray (used for multiple operatories) Statim Autoclave Washer-disinfector Ultrasonic instrument cleaner 3D Printer Milling unit Digital sensors (PSP scanner + plates, or direct sensors) Intraoral cameras Extraoral cameras / DSLR setup (photo station) Caries detection devices (laser fluorescence-type units) Mobile Nitrous Oxide System Soft Tissue Laser Hard Tissue Laser Surgical motors / implant motors Piezo surgery units (implant/perio) Endodontic motors Apex locators Obturation units Emergency equipment (AED, oxygen, etc. Vacuum mixer IV sedation setup Operatory microscopes Air abrasion units Sleep dentistry diagnostic equipment Select All This field is hidden when viewing the formEmployee'sEmployee's Name:(Required) First Last Position/Title(Required) Associate Doctor Hygienist Dental Assistant Front Office Rover Sterilization Tech Management Specialist Other If Hygienist or Doctor, Last 12 Months Production Drop files here or Select files Max. file size: 50 MB. If Hygienist or Doctor, Last 12 Months Collections Drop files here or Select files Max. file size: 50 MB. Pay Type:(Required) Hourly Salary % of Net Production % of Collection Salary Other Other Benefits(Required) PTO Health insurance 401(k) CE allowance Uniform allowance None Other Other Benefits Not Listed:(Required)Year Started(Required)Starting Wage:(Required)Or if paid on %, please list thatCurrent Wage:(Required)When was their last wage increase?(Required)How much was their last wage increase?(Required)How many hours each week do they work?(Required) Practice FinancialsAverage New Patients Per Month(Required)Last 12 Months Active Patient Count(Required)Last 18 Months Active Patient Count(Required)Last 24 Months Active Patient Count(Required)% of income from PPOs(Required)% of uninsured patients(Required)List % of Income By Insurance Company(Required)Example: Delta 44% Careington 6% Aetna 15% Accounts Receivable/Aging Report(Required) Drop files here or Select files Max. file size: 50 MB. Do not include patient creditsPatient Credits(Required) Drop files here or Select files Max. file size: 50 MB. Collections BY MONTH from the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Collections(Required)2024 Total Collections(Required)2023 Total Collections(Required)Production BY CODE for the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryProduction BY MONTH for the last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryHygiene Only Total Production BY MONTH for the last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by category2025 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2024 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2023 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Production(Required)2024 Total Production(Required)2023 Total Production(Required)Adjustments & Write Offs Total for the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Write Offs and Adjustments(Required)2024 Total Write Offs and Adjustments(Required)2023 Total Write Offs and Adjustments(Required) Taxes & Financial StatementsLast 5 years business tax returns(Required) Drop files here or Select files Max. file size: 50 MB. Last 5 years P&L and balance sheet (annual is ok; monthly is better)(Required) Drop files here or Select files Max. file size: 50 MB. Last 12 Months P&L and balance sheet through most recent month-end(Required) Drop files here or Select files Max. file size: 50 MB. General ledger for the Last 12 Months period (for add-backs support)(Required) Drop files here or Select files Max. file size: 50 MB. Owner Compenation & Add-BacksUpload accountant comp summary(Required) Drop files here or Select files Max. file size: 50 MB. Owner W-2 wages (number)(Required)Owner distributions/draws (number)(Required)Benefits paid by practice (number or “included in GL”)(Required)Upload W-2 / payroll summary for each owner(s)(Required) Drop files here or Select files Max. file size: 50 MB. Discretionary / one-time expenses Add RemoveAuto/Vehicle, Travel, Meal/Entertainment, Cell/Phone/Internet, CE/Dues, Family Payroll, One-time Legal/Accounting Remodel/Buildout one-time Other Anything else you want the appraiser to know?(Required)Client Data Accuracy & Reliance Acknowledgement (Electronic Signature Required)Picture of the Driver's License for who is filling out this form(Required) Drop files here or Select files Max. file size: 50 MB. 1) Accuracy and Completeness of Client Information I certify that all financial, operational, and other information and documents I provide (or authorize to be provided) are, to the best of my knowledge, true, accurate, and complete. I will promptly provide corrections if I discover errors or omissions.(Required)2) Reliance; No Audit or Verification I understand the valuation is based on information supplied by me and/or my advisors (CPA, bookkeeper, practice management system reports). Stephanie Wright does not perform an audit, review engagement, or forensic investigation, and does not independently verify the accuracy or completeness of the information unless expressly agreed in writing.(Required)3) Effect of Errors, Omissions, or Misstatements I understand that any errors, omissions, inconsistencies, or misrepresentations in the information I provide may materially affect the valuation results. I agree that Stephanie Wright is not responsible for any such impact caused by the information I supplied.(Required)4) No Third-Party Reliance (Buyer/Lender/Other Parties) The valuation is prepared solely for the Client’s use for the stated purpose. No buyer, lender, broker, partner, or other third party may rely on the valuation without Stephanie Wright’s prior written consent. Any unauthorized reliance is at the third party’s own risk, and I agree to communicate this limitation to any party to whom I share the report.(Required)5) Buyer Discrepancies / Alleged Misleading Information If a buyer (or any other third party) later identifies discrepancies or alleges they were misled, I understand that any such claims related to the valuation that arise from Client-provided information are the Client’s responsibility, not Stephanie Wright’s, unless a court finds Stephanie Wright engaged in intentional misconduct.(Required)6) Indemnification (Protection if a Buyer or Third Party Makes a Claim) To the fullest extent permitted by law, I agree to defend, indemnify, and hold harmless Stephanie Wright and her company/representatives from any claims, damages, losses, liabilities, or expenses (including reasonable attorney fees) arising out of or related to: inaccurate, incomplete, or misleading information provided by the Client or the Client’s advisors; the Client’s use of the valuation; or any third party’s access to or reliance on the valuation without written consent; except to the extent caused by Stephanie Wright’s gross negligence or willful misconduct.(Required)7) Attorney Fees and Time (Fee Shifting) If any claim, demand, arbitration, or lawsuit arises out of or relates to this valuation engagement, and such matter is caused in whole or in part by Client-provided information or unauthorized third-party reliance, the Client agrees to reimburse Stephanie Wright for reasonable attorney fees and costs, plus reasonable time spent responding to subpoenas, discovery, depositions, mediation, arbitration, or court proceedings, billed at $_____ per hour (or, if blank, at Stephanie Wright’s then-current hourly consulting rate).(Required)8) Limitation of Liability To the fullest extent permitted by law, Stephanie Wright’s total liability for any claims arising from this engagement will not exceed the amount of fees actually paid by the Client for the valuation services, except for liability resulting from gross negligence or willful misconduct.(Required) Dental Valuation Step 1 of 9 11% Valuation Date(Required) MM slash DD slash YYYY Practice Name(Required)Website:Practice Phone Number:(Required)Practice Email:(Required) Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Tax Entity:(Required) LLC PLLC PC S-Corp C-Corp Sole Proprietor Partnership Other Practice Type:(Required) General Dentistry Pediatric Orthodontic Periodontic Endodontic Oral Surgery Prosthodontic Multi-specialty Other (text) Other Business Type:(Required) Solo Group (2+ doctors) Hygiene Only Other Form of Sale Assumption(Required) Asset sale (assume assets + goodwill; excludes stock) Equity/stock sale (assume entity shares) Unknown — use Asset Sale assumption Other How are you selling your practice?(Required) 100% practice sale Associate buy-in / buy-out Partner dispute Estate / tax planning Divorce / litigation Financing / bank requirement Other If Partial Sale or Buy-In, % to be valued(Required)Included in the Practice Value (Only select what you are selling) Equipment & furnishings used in operations Charts/records & practice goodwill Phone numbers, website/domain, brand assets Office supplies on hand (consumable inventory) Clinical Supplies/Inventory Cash in bank Accounts receivable (AR) Real estate/building/condo unit Personal vehicles/personal assets Investments/other non-operating assets Select AllOther Assets Not Listed(Required)seller stays X months for transition; non-compete; normal staffingSeller Transition Assumption Seller leaves at closing (0 months) Seller stays 3 months Seller stays 6 months Seller stays 12 months Unknown Other If seller stays: Clinical schedule during transition(Required) 1 day/week 2 days/week 3 days/week 4 days/week 5 days/week Unknown Other What do you believe your practice should be sold for and why?(Required)When would you like this practice sold? (i.e. 3-6 months, 1 year etc)(Required) Owner and Partner/s Information:Provider/s: (Enter primary owner first) Name:(Required)Email:(Required)Cell Phone:(Required)% of ownership:(Required)What year did this provider start working for the company?(Required)What year did this provider become a partner/owner(Required)Copy of Professional License(Required) Drop files here or Select files Max. file size: 50 MB. This Partners Production By Month For The Last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. This Partners Collections By Month For The Last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Facility:Ownership/Lease(Required) Owned by doctor personally Owns condo/unit Owned by separate real estate entity (LLC, etc.) Leases from third-party landlord Sublease / shared space Lease with option to purchase (rent-to-own) Other If leased: Current monthly base rent(Required)Total Square Footage:(Required)Year facility was built(Required)Annual Property Taxes:(Required)For condo/unit, HOA fees:(Required)If leased: Monthly CAM/NNN(Required) None / Included in rent Unknown Other Lease term remaining(Required) < 1 year 1–2 years 2–5 years 5+ years Unknown Other Lease/Sublease Terms, amendments or optionsMax. file size: 50 MB. Interior Pictures of Facility(Required) Drop files here or Select files Max. file size: 50 MB. Break Room, Waiting Room, Halls, Doctors Office, Lab, SterilizationExterior Pictures of Facility(Required) Drop files here or Select files Max. file size: 50 MB. Clinical Time and UseTotal hygiene hours per week:(Required)Total Doctor Treatment Hours Per Week:(Required)Total Operatories: (including ones that are plumbed but in use)(Required)How many of those operatories are ready for care? (plumped, equipment, patient ready)(Required)How many are used for Hygiene?(Required)How many are used for Doctor?(Required)Swing/Overflow Op(Required)Is this practice chartless?(Required) Completely Paperless (with the exception of paper routers) Partially Paperless Other If not completely chartless, what is still being used in paper charts?(Required)Operatory & EquipmentOp 1 Please Only Select What Is Dedicated To This Op and are not shared. There is a section after the operatory listings where equipment such as x-ray sensors, intraoral camera's, laser's etc Used for Doctor Used for Hygiene Sink Shared Sink Piezo Laser Monitor Second Monitor Cavitron Computer Prophy Jet Lead Apron Curing Light Tablet or Ipad Overhead light Intraoral Camera Water Bottle System Plumbed Water System High Speed Handpiece Low Speed Handpiece Surgical Handpiece Transillumination Device Nitrous (fixed/plumbed) Fixed Xray Unit (Dedicated to this op only) Shared Xray Unit between operatories Select AllOther Equipment Not ListedPictures of Operatory(Required) Drop files here or Select files Max. file size: 50 MB. Other Equipment CBCT / Cone Beam CT Digital impression scanner (intraoral scanner) Panoramic X-ray unit Cephalometric add-on Transillumination caries detection Handheld X-Ray (used for multiple operatories) Statim Autoclave Washer-disinfector Ultrasonic instrument cleaner 3D Printer Milling unit Digital sensors (PSP scanner + plates, or direct sensors) Intraoral cameras Extraoral cameras / DSLR setup (photo station) Caries detection devices (laser fluorescence-type units) Mobile Nitrous Oxide System Soft Tissue Laser Hard Tissue Laser Surgical motors / implant motors Piezo surgery units (implant/perio) Endodontic motors Apex locators Obturation units Emergency equipment (AED, oxygen, etc. Vacuum mixer IV sedation setup Operatory microscopes Air abrasion units Sleep dentistry diagnostic equipment Select All This field is hidden when viewing the formEmployee'sEmployee's Name:(Required) First Last Position/Title(Required) Associate Doctor Hygienist Dental Assistant Front Office Rover Sterilization Tech Management Specialist Other If Hygienist or Doctor, Last 12 Months Production Drop files here or Select files Max. file size: 50 MB. If Hygienist or Doctor, Last 12 Months Collections Drop files here or Select files Max. file size: 50 MB. Pay Type:(Required) Hourly Salary % of Net Production % of Collection Salary Other Other Benefits(Required) PTO Health insurance 401(k) CE allowance Uniform allowance None Other Other Benefits Not Listed:(Required)Year Started(Required)Starting Wage:(Required)Or if paid on %, please list thatCurrent Wage:(Required)When was their last wage increase?(Required)How much was their last wage increase?(Required)How many hours each week do they work?(Required) Practice FinancialsAverage New Patients Per Month(Required)Last 12 Months Active Patient Count(Required)Last 18 Months Active Patient Count(Required)Last 24 Months Active Patient Count(Required)% of income from PPOs(Required)% of uninsured patients(Required)List % of Income By Insurance Company(Required)Example: Delta 44% Careington 6% Aetna 15% Accounts Receivable/Aging Report(Required) Drop files here or Select files Max. file size: 50 MB. Do not include patient creditsPatient Credits(Required) Drop files here or Select files Max. file size: 50 MB. Collections BY MONTH from the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Collections(Required)2024 Total Collections(Required)2023 Total Collections(Required)Production BY CODE for the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryProduction BY MONTH for the last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryHygiene Only Total Production BY MONTH for the last 12 Months(Required) Drop files here or Select files Max. file size: 50 MB. Do not provide production by category2025 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2024 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2023 Production By Code(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Production(Required)2024 Total Production(Required)2023 Total Production(Required)Adjustments & Write Offs Total for the last 12 months(Required) Drop files here or Select files Max. file size: 50 MB. 2025 Total Write Offs and Adjustments(Required)2024 Total Write Offs and Adjustments(Required)2023 Total Write Offs and Adjustments(Required) Taxes & Financial StatementsLast 5 years business tax returns(Required) Drop files here or Select files Max. file size: 50 MB. Last 5 years P&L and balance sheet (annual is ok; monthly is better)(Required) Drop files here or Select files Max. file size: 50 MB. Last 12 Months P&L and balance sheet through most recent month-end(Required) Drop files here or Select files Max. file size: 50 MB. General ledger for the Last 12 Months period (for add-backs support)(Required) Drop files here or Select files Max. file size: 50 MB. Owner Compenation & Add-BacksUpload accountant comp summary(Required) Drop files here or Select files Max. file size: 50 MB. Owner W-2 wages (number)(Required)Owner distributions/draws (number)(Required)Benefits paid by practice (number or “included in GL”)(Required)Upload W-2 / payroll summary for each owner(s)(Required) Drop files here or Select files Max. file size: 50 MB. Discretionary / one-time expenses Add RemoveAuto/Vehicle, Travel, Meal/Entertainment, Cell/Phone/Internet, CE/Dues, Family Payroll, One-time Legal/Accounting Remodel/Buildout one-time Other Anything else you want the appraiser to know?(Required)Client Data Accuracy & Reliance Acknowledgement (Electronic Signature Required)Picture of the Driver's License for who is filling out this form(Required) Drop files here or Select files Max. file size: 50 MB. 1) Accuracy and Completeness of Client Information I certify that all financial, operational, and other information and documents I provide (or authorize to be provided) are, to the best of my knowledge, true, accurate, and complete. I will promptly provide corrections if I discover errors or omissions.(Required)2) Reliance; No Audit or Verification I understand the valuation is based on information supplied by me and/or my advisors (CPA, bookkeeper, practice management system reports). Stephanie Wright does not perform an audit, review engagement, or forensic investigation, and does not independently verify the accuracy or completeness of the information unless expressly agreed in writing.(Required)3) Effect of Errors, Omissions, or Misstatements I understand that any errors, omissions, inconsistencies, or misrepresentations in the information I provide may materially affect the valuation results. I agree that Stephanie Wright is not responsible for any such impact caused by the information I supplied.(Required)4) No Third-Party Reliance (Buyer/Lender/Other Parties) The valuation is prepared solely for the Client’s use for the stated purpose. No buyer, lender, broker, partner, or other third party may rely on the valuation without Stephanie Wright’s prior written consent. Any unauthorized reliance is at the third party’s own risk, and I agree to communicate this limitation to any party to whom I share the report.(Required)5) Buyer Discrepancies / Alleged Misleading Information If a buyer (or any other third party) later identifies discrepancies or alleges they were misled, I understand that any such claims related to the valuation that arise from Client-provided information are the Client’s responsibility, not Stephanie Wright’s, unless a court finds Stephanie Wright engaged in intentional misconduct.(Required)6) Indemnification (Protection if a Buyer or Third Party Makes a Claim) To the fullest extent permitted by law, I agree to defend, indemnify, and hold harmless Stephanie Wright and her company/representatives from any claims, damages, losses, liabilities, or expenses (including reasonable attorney fees) arising out of or related to: inaccurate, incomplete, or misleading information provided by the Client or the Client’s advisors; the Client’s use of the valuation; or any third party’s access to or reliance on the valuation without written consent; except to the extent caused by Stephanie Wright’s gross negligence or willful misconduct.(Required)7) Attorney Fees and Time (Fee Shifting) If any claim, demand, arbitration, or lawsuit arises out of or relates to this valuation engagement, and such matter is caused in whole or in part by Client-provided information or unauthorized third-party reliance, the Client agrees to reimburse Stephanie Wright for reasonable attorney fees and costs, plus reasonable time spent responding to subpoenas, discovery, depositions, mediation, arbitration, or court proceedings, billed at $_____ per hour (or, if blank, at Stephanie Wright’s then-current hourly consulting rate).(Required)8) Limitation of Liability To the fullest extent permitted by law, Stephanie Wright’s total liability for any claims arising from this engagement will not exceed the amount of fees actually paid by the Client for the valuation services, except for liability resulting from gross negligence or willful misconduct.(Required)
