Practice Information abbreviated

Name

First NameLast Name
E-mail
Phone Number (What number do you want us to use to contact you?)

Area CodePhone Number
Practice Name
Practice Website Address
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Practice Locations
Are you the owner of the practice?

YesNo
From which school/college of optometry did you graduate?
What year did you graduate with an OD degree?
What are you looking to do?

Sell and walk awaySell and work as an employee in the practiceBring on a partner and stay for less than 5 yearsBring on a partner and stay for more than 5 yearsBring on an associate with partnership in 1 yearBring on an associate with partnership in 2 yearsBring on an associate with partnership in 3 or more yearsBuy this practice this yearBuy this practice within the next 3 yearsBuy this practice in more than 3 years
What is the legal organization of the practice?

Sole proprieterPartnershipS-CorpC-CorpLLCProfessional LLCProfessional association
Please give a brief narrative of the practice including, how long the practice has existed, how long in the current location, any specialties, any unique characteristics of the practice (i.e.: 2nd floor, inside a hospital, professional building, stand alone building, niche practice, etc).
How many total OD clinical hours occur each week on average (eg: owner ODs + Associate ODs)? These are clinical hours not administrative hours.
How many total owner clinical hours occur each week on average?
Is the practice completely HIPAA compliant?

YesNo
Are the doctors in the practice actively E-prescribing?

YesNo
Does the practice utilize a clearinghouse for 3rd party billing?

YesNo
The clinical equipment is ...

Completely ownedOutstanding loans existCurrently being leasedThe practice has borrowed equipmentThe practice has shared equipment with other practicesMultiples of the above are true
In the last 12 months, what is the total number of complete exams with refractions of new patients?
In the last 12 months, what is the total number of complete exams with refractions of established patients?
In the last 12 months, how many patients seen were 0-17 years of age?
In the last 12 months, how many patients seen were 18-39 years of age?
In the last 12 months, how many patients seen were 40-64 years of age?
In the last 12 months, how many patients seen were over 64 years of age?
What is the total number of frames displayed not including sunglasses?
What is the total number of sunglasses displayed?
What is the total number of office square feet including the optical?
What is the total number of square feet of just the optical?
What percentage of the practice gross revenue collected is medical?
What percentage of the practice gross revenue collected is optical?
Name the Practice Management Software used in the practice.
Describe the use of electronic medical records in the practice.
Describe the use of a patient portal in this practice.
Is the practice participating in a Shared Overhead situation?

YesNo
Approximately how many patients per year do all of the ODs in the practice co-manage?
Are any of the doctors in the practice MDs or DOs?

YesNo
Will the landlord renew the lease with the buyer?

YesNo
Please upload an excel spreadsheet for regular staff who are not doctors with the following columns: First name with last name initial, Description of duties, Ave hours per week, Hourly pay rate, Annual total wage-bonus-benefit package value.

Upload a File

Cancelof
Please upload an excel spreadsheet for each doctor (associate and owner) with the following columns: First name with last name initial, Description of duties, Ave hours per week, Hourly pay rate, Annual total wage-bonus-benefit package value.

Upload a File

Cancelof
Please upload the most current year of Federal tax returns for the practice.

Upload a File

Cancelof
Please upload last year's Federal tax returns for the practice.

Upload a File

Cancelof
Please upload the year before last of Federal tax returns for the practice.

Upload a File

Cancelof
Please upload the most current annual P&L Statement for the practice.

Upload a File

Cancelof
Please upload the most current interim P&L Statement for the current tax year.

Upload a File

Cancelof
Please upload the most current Balance Sheet for the practice for the beginning of the most current year (eg: Jan 1).

Upload a File

Cancelof
Please upload the Balance Sheet for the practice for beginning of last year (eg: Jan 1).

Upload a File

Cancelof
How much in total was paid (wage + bonus + benefits + pension + profit) to the selling doctor for 2019?
How much in total was paid (wage + bonus + benefits + pension + profit) to the selling doctor for 2018?
How much in total was paid (wage + bonus + benefits + pension + profit) to the selling doctor for 2017?
How much in total was paid (wage + bonus + benefits + pension + profit) to the selling doctor for 2016?
How much in total was paid (wage + bonus + benefits + pension + profit) to employee (non-owner) doctors for 2019?
How much in total was paid (wage + bonus + benefits + pension + profit) to employee (non-owner) doctors for 2018?
How much in total was paid (wage + bonus + benefits + pension + profit) to employee (non-owner) doctors for 2017?
How much in total was paid (wage + bonus + benefits + pension + profit) to employee (non-owner) doctors for 2016?
How much in total was paid (wage + bonus + benefits + pension + profit) to non-doctor employees for 2019?
How much in total was paid (wage + bonus + benefits + pension + profit) to non-doctor employees for 2018?
How much in total was paid (wage + bonus + benefits + pension + profit) to non-doctor employees for 2017?
How much in total was paid (wage + bonus + benefits + pension + profit) to non-doctor employees for 2016?
Upload a picture of the outside of the practice.

Upload a File

Cancelof
Upload a picture of the reception area of the practice.

Upload a File

Cancelof
Upload a picture of a typical exam room in the practice.

Upload a File

Cancelof
Upload a picture of the special testing area of the practice.

Upload a File

Cancelof
Upload a picture of the optical portion of the practice.

Upload a File

Cancelof
Do the practice have an in-house optical where spectacle lenses are finished or edged?

NoYes, just edgingYes, just finishingYes,both edging and finishing
Upload a picture of the in-house optical where spectacle lenses are finished or edged.

Upload a File

Cancelof
Upload a CPT analysis report for the last complete month.

Upload a File

Cancelof
Upload an ICD analysis report for the last complete month.

Upload a File

Cancelof
Do the practice use a buying group? If yes, please name them.
Do the practice belong to an optometric alliance? If yes, please name them.
Is the selling doctor a Vision Source Administrator?

YesNo
Is the practice a VSP Premier practice?

YesNo
Thank you! You have now completed inputting data about the practice.

Do not forget to click on SUBMIT below to transfer the practice information to us.
Should be Empty: