Practice Valuation Application

ADS Logo
Practice
Valuation
Application
ADS South, LLC
11456 Pruett Road
Seffner, FL 33584

770-664-1982
Fax: 678-965-1812
info@adssouth.com
www.adsstouh.com

All ADS companies are independently owned and operated

Owner Personal Information - Please fill in completely

Degree
If incorporated, are you a “C” or an “S” Corporation?
Corporation Suffix
Name any other officers and all shareholders by percent interest
Do you own or practice in another practice? List addresses

List of Required Items

Provide the last three years of one of the following:
whichever tax return you have filed.
The following reports from your practice management software, as available
If you need help getting these reports, you may contact Kelley Halvorsen 727-686-3773 for help in producing these reports.
To send any items that cannot be scanned or faxed, we suggest FedEx to 11456 Pruett Road, Seffner, FL 33584
You may also email your forms to: info@adssouth.com

Personal Data

$
$

Office Data

$
$
$
$
$
$

Post-Sale Information

Enter number of days/week you would like to work for the buyer after the sale

Practice Data

$
%
%
%
%
%
%
%
%
%

Scheduling Data

%
$
$
Accounts Receivable:
$
$
$
$
$

Production By Service

For Hygiene percentage, include only the percentage actually performed by hygienists and not any other production percentage such as exam fees, etc. that were performed by Producers other than Hygienists.

%
%
%
%
%
%
%
%
%
%
%
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%
If so, how much for each year?
$
$
$

Fee Schedule

$
$
$
$
$
$
$
$
$
$

Demographic Data

Staff Data

$
$
or
%
$
What position do they hold and what is the estimated fair market value of their job?
$
Which positions and amount of over/under compensation for each?

Collection Centers

For Hygienist collections, include only production actually performed by hygienists and not any other production such as exam fees, etc. that were performed by Producers other than Hygienists.

Year
to
Gross Collections
$
$
$
Owner
$
$
$
Hygienists
$
$
$
Associate
$
$
$
Associate
$
$
$
Associate
$
$
$
How is associate compensated? Amount?
$
or
%
How is hygienist compensated? Amount?
$
or
%

Practice Conformity Data

Insurance Explanation

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$
$
$
$
$
$

Taxes and Licenses Explanation

$
$
$
$
$
$

Pension Explanation

$
$
$

Benefits Explanation

$
$
$

Insurance Plans

%
%

Specialty Practice Supplement for Orthodontic Practices

Total number of patients in treatment:
Complete banding treatment patients:
Partial banding treatment patients:
Number of patients in partial treatment:
Patients in retention:
$
Jan. 1, 20
Cost of average full treatment:
$
$
$
$
$
Average fee per retention patient:
$
$
Average fee for partial treatment:
$
$
$
Do you use:
%
%
%
%
%

Specialty Practice Supplement for Oral Surgery Practices

What percent of practice is:
%
%
%
%
%
%
%

Specialty Practice Supplement for Periodontal Practices

What percent of practice income is:
%
%
%
%
%
%

Equipment List

Reception

Private Office

Business Office

Lounge

Mechanical

X-Ray Equipment

Sterilization

Tanks

Lab

Hygiene #1

Operatory #1

Other

List any other equipment to be included

List any items not to be included

I attest that all of the information that I have provided to ADS South, LLC is true to the best of my knowledge and that there are no omissions of any information that would materially alter the value, desirability, or performance of my practice.

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