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Seller Practice Questionnaire
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Non-disclosure Sign-up
Seller Practice Questionnaire

Seller Form

Get a head start on your practice search by sending us your completed confidentiality forms. Agreeing to our confidentiality policy will allow us to share detailed information about the practice opportunities that interest you. Thank you!
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Consani Associates

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(866) 348-3800 fax (866) 348-3809

CONFIDENTIAL PRACTICE QUESTIONNAIRE

Education/Experience/Building Information

The description above accurately describes my practice to the best of my knowledge.

Requested Practice Data/Reports

Please, upload the following files:

  • The Last 3 Business Tax Returns
  • Copy of Profitand Loss –Current and most recent year
  • Fee Schedule(s) for cash/creditand top three insurances if different
  • Equipment List (if available)
  • Accounts Receivable Aging Report (30, 60, 90, over 90---Totals only)
  • Monthly production and collection totals only for current year
  • Current and Previous year -Production by Procedure Code Report
  • Last full year -Revenue listed by cash/credit and by each insurance company
  • Associate Agreement and theirwages and production total–Current and Previous Year
  • Copy of Office Lease (if applicable)
  • If applicable, Partnership Agreements

Please provide the following staff information:

All information remains confidential.