DJS | Dentist Job Search - Opinion of practice value registration form

Opinion of practice value registration form

Contacts
Business:	*
Home:
Mobile:
Business fax:
Home fax:
Email:
Preferred contact:	(to select multiple options press control/command & click again)

Exiting principal/s profile
How many hours per week is the exiting/s principal working?
How many years has the exiting principal/s conducted the practice?
What percentage of the exiting principal's turnover is made up of:
General dentistry:	%
Orthodontics:	%
Oral surgery:	%
Endodontics:	%
Periodontics:	%

Exit plan - Is the exiting principal:
	Selling to associate
	Available to remain in practice as an employee for an extended period (over one year)
	Available to remain in practice as an employee for a short period to introduce the incoming dentist
	Wanting to sell and exit
	Selling to work elsewhere in the area

Practice description
Associates
Number of full-time associates: (exc principal)
Number of part-time associates: (exc principal)
Employee dentists
Number of full-time employee dentists:
Number of part-time employee dentists:
Hygienists
Number of full-time hygienists:
Number of part-time hygienists:

Number of surgeries:
Rooms suitable for operatory:
Size of the practice: (in square meters)
Practice opening hours per week:
Average new patients per month:
Number of active patients: **
How many comparable dental practices are there in the area?
** The number of active patients is defined as the number of unique patients that visited your practice in the last 18 months.

Premises description
Premises: (describe presentation, quality and condition of fittings and furnishings)
How long ago did you last refurbish?
Location: (accessibility to the practice, exposure in the city, suburb or town)
Lease on premises: (length of term to run, options)
How many years has the practice been in this location?
Any additional information:

Other relevant information on overheads
Details:

Payment details
All fees are GST inclusive and in $AUD
	I require a written market valuation ($1,650.00)
Payment method:
Amount:	$ 0.00
Please make cheques and money orders payable to Dentist Job Search P/L.

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Accuracy of information
	I hereby certify that all information supplied on this date is, to the best of my knowledge, totally accurate. *

Image verification
If you can't read the code, click here	Please enter the five letters that appear in the image opposite. *

In order to complete the valuation process we will also require the following documentation:

Profit and Loss Statements for the last 2 years;
Depreciation Schedule for the last 2 financial years;
Any other purchases or refurbishments in the last 5 years not already listed in the questionnaire.
Some practice photos.

Please send these to:

Level 1, 100 Fyans St
South Geelong VIC 3220
Australia

Alternatively, you can fax them to us on +61 3 5255 5511 or send them by email at admin@djs.com.au.

Fields marked with an asterisk (*) are compulsory.