Potential Sale of Practice - Preliminary Questionnaire

  • Facility Infomation

  • Date Format: MM slash DD slash YYYY
  • Owners% of Ownership 
  • Location 1Location 2Location 3 
  • Location 1Square FeetYears on LeaseAssignable 
  • AudiologistLicensed DispensersFront Office StaffAdministrative StaffOther 
  • AudiologistLicensed DispensersFrontAdminOther 
  • Financial Information

  • Private PayInsuranceMedicaid3rd Party 
  • Dispenser201620172018 
  • 201620172018 
  • 201620172018 
  • Patient Data

  • Take the number of new patients for the last 12 months and divide by 12
  • ManufacturerPercentage 
  • patients seen in the past 24 months
  • New - %Existing - % 
  • Owner Transition

  • Please describe
  • Additional Documents needed from your office

  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
  • Accepted file types: pdf.
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