Buck: (503) 680-4366
Megan: (503) 830-5765
Rod: (206) 979-2660
3519 NE 15th Ave,
Portland, OR 97212-2356

Confidential Buyer Interview Form

Buying and selling a practice requires both parties to share significant information with each other. If you have been considering purchasing your own dental practice, let us help you. Please take a moment to fill out our form below. All information you provide us will be kept strictly confidential. Once submitted we will contact you by your preferred method of contact to discuss your needs and concerns. We look forward to hearing from you.

 
 

Personal Information

First name: *

Last name: *

Email address: *

Date of Birth:

Spouse's Name:

Other Languages Spoken:

Right or Left Handed:

left right

 

Home

Home address:

City:

State:

Zip:

Evening Phone:

Day Phone:

Cell Phone:

 

Office

Office address:

City:

State:

Zip:

Office Phone:

Office email:

Fax:

 

Preferred method of contact: *

I am looking for:

I am looking to buy:

Practice type:

Desired setting:

Ideal practice information:

Present Status

 Student

Dental school:    Graduation year: 

 Training/Residency

Date completed:    Focus area: 

 Military

Branch:    Exit date: 

 Associate

Years in practice:    Covenant terms: 

 Employee

Years in practice:    Covenant terms: 

 Own practice

Years in practice:    Other notes: 

 

State boards passed (include dates):

Regional boards passed (include dates):

 

Desired Practice Size

Annual gross receipts:

Number of operatories:

Price range:

 

My timeframe:

How did you hear about us?

Comments/Questions:

 
 

It may take a moment to submit your information. Please wait for a confirmation message.


UPCOMING EVENTS
2018 Events Preview

Portland Midwinter Practice Transition Seminar
MAC Club
Friday, January 26, 2018

Seattle Midwinter Practice Transition Seminar
Bellevue Club
Friday, February 2, 2018

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Reasor Professional Dental Services merging with Omni Practice Group | www.reasorprofessionaldental.net | 503-680-4366
3519 NE 15th Ave., #201, Portland, OR 97212



 

 

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