Buyer Registration
Title
*
First Name
*
Last Name
*
Email
*
I would describe myself as
*
Select
Endodontist
General Dentist
Multi-specialist
Oral Surgeon
Orthodontist
Pedodontist
Periodontist
Prosthodontist
Are you a U.S. Citizen?
*
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Yes
No
Date of Birth
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Home Address
*
City
*
State
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip
*
Primary Phone Number
*
Current Status
*
Select
Associate
Dental Practice Owner
Residency
Student
Undergraduate School
Dental School
*
Do you have an Active Virginia/DC Dental License?
*
Select
Yes
No
Dental School Graduation Date
*
Day
01
02
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25
26
27
28
29
30
31
Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
Year
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
Type of Practice Opportunity you're seeking:
*
Select
Endodontics
General Dentistry
Multi-specialty
Oral Surgery
Orthodontics
Pedodontics
Periodontics
Prosthodontics
Specialty/Other Training
*
Select
Endodontics
General Dentistry
Multi-specialty
Oral Surgery
Orthodontics
Pedodontics
Periodontics
Prosthodontics
Professional Experience
*
Associate
Military
Owner
Partner
Student/Residency
If you are a DSO, please list what organization you are with.
*
Currently bound by Non Compete?
*
Select
Yes
No
Approximately how much is the operative production with your current employer?
*
Select
Less Than $200K
$200-300K
$300-500K
$500-600K
More Than $600K
Have you ever owned a Dental Practice?
*
Select
Yes
No
What type of buyer are you?
*
Select
Dental Service Organization
Multi-Practice
Sole Proprietor
Region most Desired - 1st Choice?
*
Select
Northern Virginia
Southwest Virginia
Central Virginia
Eastern Shore
Entire State of Virginia
Washington, DC
Region most Desired - 2nd choice
*
Select
Northern Virginia
Southwest Virginia
Central Virginia
Eastern Shore
Entire State of Virginia
Washington, DC
Do you have a particular area in Virginia in which you would like to own a practice in?
*
Select
Alexandria
Bristol
Buena Vista
Charlottesville
Chesapeake
Colonial Heights
Covington
Danville
Emporia
Fairfax
Falls Church
Franklin
Fredericksburg
Galax
Hampton
Harrisonburg
Hopewell
Lexington
Lynchburg
Manassas
Manassas Park
Martinsville
Newport News
Norfolk
Norton
Petersburg
Poquoson
Portsmouth
Radford
Richmond
Roanoke
Salem
Staunton
Suffolk
Virginia Beach
Washington, DC
Waynesboro
Williamsburg
Winchester
No Preference
Do you have a preferred 2nd area in Virginia in which you would like to own a practice?
*
Select
Alexandria
Bristol
Buena Vista
Charlottesville
Chesapeake
Colonial Heights
Covington
Danville
Emporia
Fairfax
Falls Church
Franklin
Fredericksburg
Galax
Hampton
Harrisonburg
Hopewell
Lexington
Lynchburg
Manassas
Manassas Park
Martinsville
Newport News
Norfolk
Norton
Petersburg
Poquoson
Portsmouth
Radford
Richmond
Roanoke
Salem
Staunton
Suffolk
Virginia Beach
Washington, DC
Waynesboro
Williamsburg
Winchester
No Preference
What type of environment would you like to most practice in?
*
Select
Urban
Suburban
Rural
No Preference
What do you estimate your FICO score to be? (We recommend myfico.com, as a secure way to find this, however Experian score will suffice).
*
Select
Less Than 600
600-650
650-700
700-750
Greater Than 750
Have you pre-qualified to purchase a dental practice by a specific Dental lender?
*
Select
Yes
No
If you have been pre-approved, which lender?
*
If you have been pre-approved, how much have you been pre-qualified for?
*
Select
N/A
Up to $300K
$300K-500K
$500K-700K
$700K-900K
Over 900K
Attorney First Name
*
Attorney Last Name
*
Attorney Email
*
Attorney Phone
*
CPA First Name
*
CPA Last Name
*
CPA Email
*
CPA Phone
*
How did you hear about us?
*
Select
Google
Social Media
Word of Mouth
Email
Direct Mail
Newspaper/Print
Website
Other
I have read the Disclaimer and Agree to the Confidentiality Agreement.
*
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Confirm
Submit