Seller Inquiry Form

In order to expedite your inquiry, please feel free to provide us with the following information.

Would you like the information submitted in this form kept confidential? *

Yes No

Type of Practice * Size of Practice (Gross Receipts) *

Doctor's Name * Business Name *
Business Address * City * State * Zip Code *
Business Phone * Fax E-mail * Mobile *

Mailing Address * City * State * Zip Code *

Age of Practice * # of Ops. *

Patient Mix:

% Private * % Ins. * % PPO * % HMO * % MediCal *

Comments (Reason for selling, relocating, retiring, etc.)

Verification