ADS Precise Consultants

Buying a Dental Practice

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Fill out and return the Buyer Forms

pdf_iconBuyer Forms

If you are interested in detailed information about practice purchase opportunities, we will need your promise of non-disclosure. This entails no cost or obligation other than your confidentiality. You can print this form above, complete it and send it to us or fax it to (303) 675-6161, or complete the online form:

Prospective Buyer/Associate Form

General Information


First Name (*)

Please enter your first name.
Last Name (*)

Please enter your last name.
Email Address (*)

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Preferred Primary Phone (*)

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Preferred Secondary Phone

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Home Address (*)

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City (*)

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State

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Zip Code (*)

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Date of Birth (*)

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Spouse's First Name

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Education



Professional Degree (*)

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Date Received (*)

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Dental School (*)

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Specialty/Residency

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Date Specialty/Residency Completed

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Dental Experience

(please list where & when you owned practices, were an associate, or had salaried positions and dates of each)

Name & Address

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Dates

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Name & Address

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Dates

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Licenses



State/Region

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License #

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Date

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State/Region

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License #

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Date

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Type of Practice/Position



GP/Specialty

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What are you interested in?



Please tell us your first priority (*)





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What is your second priority (*)





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What is your third priority (*)





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What is your fourth priority (*)





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States/Cities/Areas

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Please describe the characteristics of a practice that would interest you

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Practice Gross Revenue per year

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Practice Net Income per year

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Time Frame



By what date would you ideally want to purchase a practice or start as an associate?

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Do you need to sell a practice before you purchase a practice?



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If yes, please explain

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Financing the Purchase

If you will need a loan to purchase a practice, ADS Precise Consultants can usually assist you in securing financing, in an amount equal to 100% of the purchase price plus working capital, if needed. If you have been out of school for less than 2 years, the banks may require that you have a cosigner for the loan.

Would you like your contact information to be sent to lenders?



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Do you have any cosigners for a loan?



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Relationship

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Have you ever declared bankruptcy?



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If yes, please explain / What year?

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Are there any unsatisfied judgments against you or any business that you have owned?



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If yes, please explain

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Military Service/Specialty/Residency



Are you presently in:




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Branch

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Years Served

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Rank

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Date of Separation/Discharge/Completion

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Are you using a buyer's agent?



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If yes, who?

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ADS Precise Consultants has no obligation to and will not pay a buyer's agent. Notify us if you have signed a buyer's agent agreement with any firm.



NON-DISCLOSURE OF CONF IDENTIAL INFORMATION AND PROSPECTIVE BUYER/ASSOCIATE AGREEMENT

Please read in its entirety and check the box at the bottom of this page.

Your Legal Name (*)

Please enter your legal name.

This agreement shall be enforced in accordance with the laws of the state of Colorado. Prospective Buyer/Associate wishes to evaluate confidential information regarding practice opportunities presented by Broker.

• Prospective Buyer/Associate recognizes that any confidential information provide him/her by Broker or its representative regarding professional practices could, if disclosed, cause damage to the individuals disclosing the information and to Broker.

• Therefore, Prospective Buyer/Associate agrees that he/she will not divulge, communicate, or otherwise disclose any confidential material provided by Broker, its representatives, or clients of Broker, to anyone,including employees, customers, clients or prospective clients, with the exception of his/her spouse, accountant, and legal counsel.

• Prospective Buyer/Associate further agrees that his/her spouse, accountant, and legal counsel will maintain the confidentiality of the material as well.

• Confidential information shall include, but is not limited to, the following:

1. A professional intent to buy, sell, or associate.

2. Any financial data provided Prospective Buyer/Associate by Broker, its representatives, or clients, which may included such items as value of practice under consideration, income statement or balance sheets, Internal Revenue Service returns, and any other personal financial data.

3. Any personal information provided Prospective Buyer by Broker, its representatives, or clients, which may include such items as data regarding lawsuits, pending lawsuits, malpractice suits, or other items personally pertaining to the principals in these transactions.

4. Patient or client lists made known to Prospective Buyer/Associate during negotiations. Prospective Buyer/Associate shall not contact any staff member of an owner referred to Prospective Buyer/Associate by Broker without the express permission of the owner. Prospective Buyer/Associate agrees to return any and all information provided to Prospective Buyer/Associate to Broker immediately upon request.

In addition, Prospective Buyer/Associate acknowledges the following:

1. Broker is seller's agent and does not have any fiduciary duties to Prospective Buyer/Associate.

2. Information provided by Broker is provided by the Seller and is not audited by Broker. Broker makes no claims as to the reliability of any such data.

3. It is Prospective Buyer/Associate's sole responsibility to conduct his/her own due diligence and confirm the accuracy of all information provided to Prospective Buyer/Associate by the owner and Broker prior to any purchase.

4. Prospective Buyer/Associate indemnifies and hold s Broker harmless for any claim, loss or damages including expense of defense arising from any transaction agreed to by Prospective Buyer/Associate, including but not limited to court costs, reasonable attorneys' fees and investigation expenses which, in any manner, arise out of or result from any practice purchase, employment, or affiliation;

5. Prospective Buyer/Associate is advised prior to an y purchase, to review all financial and tax records of any practice, as well as personally perform a patient chart audit (subject to HIPAA regulations), determine patient count, review insurance plans, review HMO contracts, and any other information needed by Prospective Buyer/Associate;

6. Prospective Buyer/Associate acknowledges that Broker is not an accounting firm and not a legal firm. Prospective Buyer/Associate has been advised to retain the services of competent and experienced legal counsel to review all agreements and other documents to be executed in connection with the sale/affiliation. Advice or opinion on the advisability of entering into a transaction shall be provided by Prospective Buyer/Associate's legal counsel. Prospective buyer agrees any disputes regarding this document and any future transactions between the buyer the seller and the Broker shall be resolved by JAMS Arbitration.

7. Prospective Buyer/Associate has been advised to retain the services of an accountant to evaluate the data and the terms of the affiliation or sale including any tax liability resulting from such sale/affiliation.

8. All information provided to Broker by Prospective Buyer/Associate is true and correct to the best of Prospective Buyer/Associate's knowledge, and may be presented to the owner of any practice under consideration for employment or acquisition by Prospective Buyer/Associate;

9 Upon completion of a transaction with Prospective buyer/Associate, Broker shall be permitted to print, publish and mail its usual and customary professional announcement of the transaction;



(*)

Please acknowledge that you have read and agree to the terms.

Comments or Questions?

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