Potential Sale of Practice - Preliminary Questionnaire Facility InfomationDate MM slash DD slash YYYY PhoneName of Business Name of OwnersOwners% of Ownership Reason for Selling Practice Type of Entity Sole Proprietorship LLC S Corp C Corp Number of Locations Address of LocationsLocation 1Location 2Location 3 If Renting - What is the current monthly rent amount?Location 1Square FeetYears on LeaseAssignable Number of EmployeesAudiologistLicensed DispensersFront Office StaffAdministrative StaffOther Employee WagesAudiologistLicensed DispensersFrontAdminOther Years practice has been in business Same Ownership? Yes No If No, Name of previous Owner Did you start the business? Yes No Does the owner fit Hearing Aids? Yes No If Yes, what % of total fittings? Number of Staff that dispense Hearing Aids Financial InformationDoes the business accept insurance? Yes No If Yes, what are the major carriers accepted? Please provide the overall sales for the following categoriesPrivate PayInsuranceMedicaid3rd Party Hearing Aid revenue for each dispensing staff over the last 12 monthsDispenser201620172018 Total Number of Hearing Aids sold for each of the last three years201620172018 Total Number of Patients that purchased in the last three years201620172018 Patient DataNumber of Tested Not Sold 2018 Number of Tested No Lost 2018 Number of Hearing Aid Evaluation's (Audio) for past 12 months Number of Hearing Aid Evaluation's (Audio) for new patients Number of Hearing Aid Evaluation's (Audio) for existing patients Number of new patients per month Take the number of new patients for the last 12 months and divide by 12Products (Manufacturer) fit/soldManufacturerPercentage How many patients do you see each month? Total number of active patients patients seen in the past 24 monthsHow many hearing aids are sold/fit a month (average)? ASP (Average Selling Price): $ Are you currently using a computerized/automated CRM system (sycle.net, etc)? Yes No If so, which one Please provide the percentage of sales to new vs. existing patientsNew - %Existing - % If you have not had your business appraised, do you have an 'asking price' in mind? Yes No If Yes, what is that price? Does any person or entity have a 'Right of First Refusal' (ROFR) for the purchase of your practice? Owner TransitionWould owner stay on if business was sold? Yes No If Yes, what period of time would they be willing to commit to? What would be the owners salary expectation (annually) ? Do you think the staff would stay on?Please describeDo you have any relationships with referring physicians Yes No Please describe the relationshipAdditional Documents needed from your officeCash and Accrual P&LAccepted file types: pdf, Max. file size: 50 MB.Balance Sheet for previous 2 yearsAccepted file types: pdf, Max. file size: 50 MB.Past two year tax returnsAccepted file types: pdf, Max. file size: 50 MB.Copy of LeaseAccepted file types: pdf, Max. file size: 50 MB.Equipment List with Value of Each ItemAccepted file types: pdf, Max. file size: 50 MB.Breakdown of insurance revenue by insurance payorAccepted file types: pdf, Max. file size: 50 MB.Copies of any lease documentsAccepted file types: pdf, Max. file size: 50 MB.Copies of any prior valuations of the businessAccepted file types: pdf, Max. file size: 50 MB.EmailThis field is for validation purposes and should be left unchanged.