Potential Sale of Practice - Preliminary Questionnaire Facility InfomationDate MM slash DD slash YYYY PhoneName of Business Name of person you are working with* 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 Years practice has been in business Same Ownership? Yes No If No, Name of previous Owner Did you start the business? Yes No Financial InformationProfit and Loss - 1 Year PriorMax. file size: 50 MB.Profit and Loss - 2 Years PriorMax. file size: 50 MB.Profit and Loss - 3 Years PriorMax. file size: 50 MB.Balance Sheet - 1 Year PriorMax. file size: 50 MB.Balance Sheet - 2 Years PriorMax. file size: 50 MB.Balance Sheet - 3 Years PriorMax. file size: 50 MB.Tax Returns - 1 Year PriorMax. file size: 50 MB.Tax Returns - 2 Years PriorMax. file size: 50 MB.Tax Returns - 3 Years PriorMax. file size: 50 MB.Patient DataTotal Sales Report - 1 Year PriorMax. file size: 50 MB.Total Sales Report - 2 Years PriorMax. file size: 50 MB.Total Sales Report - 3 Years PriorMax. file size: 50 MB.Total Hearing Aid Sales Report - 1 Year PriorMax. file size: 50 MB.Total Hearing Aid Sales Report - 2 Years PriorMax. file size: 50 MB.Total Hearing Aid Sales Report - 3 Years PriorMax. file size: 50 MB.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 officeCopy of LeaseAccepted 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.NameThis field is for validation purposes and should be left unchanged. Δ
