Step 1 of 9 11% Valuation Date(Required) 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussian FederationRwandaSaint 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 TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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. Addt Doctor: 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. Operatory Other Equipment CBCT / Cone Beam CT Digital impression scanner (intraoral scanner) Panoramic X-ray unit Cephalometric add-on 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) Extraoral cameras / DSLR setup (photo station) Caries detection devices (laser fluorescence-type units) Mobile Nitrous Oxide System Laser Surgical motors / implant motors Piezo 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 AllLaser DetailsPlease list each laser in the practiceType of laser (soft tissue, hard tissue, or both)Brand and modelYear acquiredApproximate current valueOwned outright, financed, or leasedWhich operatory or shared Add RemoveAdd one row per laser. Use the plus sign to add another row. Employee'sEmployee's Name:(Required) First Last Position/Title 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: Hourly Salary % of Net Production % of Collection Other Other Employee Benefits Select All PTO Health Insurance CE Allowance 401k Uniform Allowance None Benefits 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)Untitled 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 Drop files here or Select files Max. file size: 50 MB. Do not include patient creditsPatient Credits Drop files here or Select files Max. file size: 50 MB. Collections BY MONTH from the last 12 months Drop files here or Select files Max. file size: 50 MB. Total Collections, most recent completed calendar year(Required)Calendar years, most recent completed year first.Total Collections, one calendar year prior(Required)Total Collections, two calendar years prior(Required)Total Collections, last 12 months(Required)The 12 months ending with your most recent closed month.Production BY CODE for the last 12 months Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryProduction BY MONTH for the last 12 Months 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 Drop files here or Select files Max. file size: 50 MB. Do not provide production by categoryProduction By Code, most recent completed calendar year Drop files here or Select files Max. file size: 50 MB. Production By Code, one calendar year prior Drop files here or Select files Max. file size: 50 MB. Production By Code, two calendar years prior Drop files here or Select files Max. file size: 50 MB. Total Production, most recent completed calendar year(Required)Total Production, one calendar year prior(Required)Total Production, two calendar years prior(Required)Total Production, last 12 monthsAdjustments & Write Offs Total for the last 12 months Drop files here or Select files Max. file size: 50 MB. Total Write Offs and Adjustments, most recent completed calendar year(Required)Total Write Offs and Adjustments, one calendar year prior(Required)Total Write Offs and Adjustments, two calendar years prior(Required)Total Write Offs and Adjustments, last 12 months Taxes & Financial StatementsLast 5 years business tax returns Drop files here or Select files Max. file size: 50 MB. Complete federal returns as filed, all pages, schedules, statements, and elections, for the last 3 to 5 full years: Form 1120, 1120-S with all K-1s, 1065 with all K-1s, or Schedule C with the full 1040 if a sole proprietorship. Please include Schedule L balance sheet, Schedule M-1 and M-2, officer compensation schedule, and Form 4562.Last 5 years P&L and balance sheet (annual is ok; monthly is better) Drop files here or Select files Max. file size: 50 MB. Last 12 Months P&L and balance sheet through most recent month-end Drop files here or Select files Max. file size: 50 MB. General ledger for the Last 12 Months period (for add-backs support) Drop files here or Select files Max. file size: 50 MB. Business Income Tax ReturnsComplete federal returns as filed, all pages, schedules, statements, and elections, for the last 3 to 5 full years.Schedule L balance sheet, Schedule M-1 and M-2, officer compensation schedule, and Form 4562 Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Only if these are not already included in the complete returns uploaded above.Most recent extension Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Draft return or accountant's trial balance for the latest year Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Only if the latest year has not yet been filed.State income or franchise tax returns for the same years Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Depreciation and Asset DetailFixed asset and depreciation schedule Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Please include acquisition date, description, original cost, method, life, accumulated depreciation, and net book value.Section 179 and bonus depreciation detail Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Form 8594 asset acquisition statement Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. If you previously purchased the practice or a prior owner’s interest.Payroll and Contractor FilingsForms 941 for the last 12 quarters, plus annual reconciliations Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. W-2 and W-3 for the owner and staff for the same years Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. State unemployment and withholding returns Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. 1099-NEC or 1099-MISC issued to associate dentists, hygienists, or other contractors Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Retirement plan documents, and Form 5500 if filed Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Please include employer contribution amounts by year and by participant category (owner versus staff).State and Local FilingsSales and use tax returns Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Business personal property tax rendition or filing Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Please include the asset listing.Local business license or gross receipts filings Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Entity and Status ItemsEIN assignment letter Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Form 2553 S election Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. If applicable.Documentation of any entity change, ownership change, or restructuring during the lookback period Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. IRS or state notices, audit correspondence, installment agreements, liens, or unpaid payroll tax balances Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Accountant AccessYour returns need to reconcile to your internal profit and loss statements and to your practice management collections reports. Having your accountant available for questions keeps that step quick.Accountant's nameAccounting firmAccountant's phone numberAccountant's emailDo you give permission for Stephanie Wright to contact your accountant with reconciliation questions? Yes No Signed written permission to speak with your accountant Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, zip, Max. file size: 50 MB. Only if your accountant requires a signed release. Owner Compensation & Add-BacksUpload accountant comp summary 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) 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 OtherEBITDA Inputs (Last 12 Months)Total operating expenses, last 12 months (number)(Required)Interest, depreciation and amortization, last 12 months (number)(Required)Owner's clinical production, last 12 months (number)(Required)Total rent, last 12 months (number)(Required)Non-owner doctor compensation, last 12 months (number)(Required)Estimated current fair market value of all equipment, technology and leasehold improvements (number)(Required)Owner benefits paid by practice, last 12 months (number)(Required)Total discretionary and one-time add-backs, last 12 months (number)(Required) 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 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)Your NameYour NameYour NameYour Name2) 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)Your NameYour NameYour NameYour Name3) 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)Your NameYour NameYour NameYour Name4) 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)Your NameYour NameYour NameYour Name5) 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)Your NameYour NameYour NameYour Name6) 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)Your NameYour NameYour NameYour Name7) 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)Your NameYour NameYour NameYour Name8) 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)Your NameYour NameYour NameYour Name
