Transcription
PracticeValuation ApplicationADS Lovelace and Associates, Inc.Gretchen O. Lovelace, CFP, CPM, MS2120 Rue BienvenueBaton Rouge, Louisiana 70809Phone: 225-927-8015 Cell: 225-892-5135Fax: 225-927-8115Email: golovelace@gmail.comPreston L. Lovelace, JD, MSCell: 225-614-7700Email: Plovelace@gmail.com
PRACTICE PROFILEPlease print in BLACK INK and return completed forms with all additional information requested.Incomplete responses and failure to provide all information requested delays starting AppraisalAll pages except 1 and 2 will be included in the Valuation Report.GENERAL INFORMATIONCheck all that apply:DEGREE:BUSINESS ORGANIZATION TYPE:D.M.D. Other( )D.D.S.P.C.P.A.Owner’s Name:Inc.OtherM.I.LastCorporate or other Practice Name:Corporate:Sole ProprietorPartnershipFirstDate of Birth:C CorpS CorpPresident’s Name:Vice-President’s Name:Secretary’s Name:Office Address:City:Parish/County:Suite #:State: Zip:Home Address:City:Website:State:Zip:Your preferred location to direct our correspondence:HomeOfficeEmailFaxOtherSpouse’s Name:FirstM.I.LastIf Divorced, is property settlement final? Y NOffice Phone:Office Backline:Office Fax:[Secure: Y N]Pager:Home Phone:Cell Phone:Home Fax:[Secure: Y N]Secure Email:May we send confidential communications to the above secure areas?YesNoPurpose of the Appraisal:Your urgency if selling the practice:(Enter a number from 1 to 10. “10” represents selling in 30 days. “1” represents selling in 2 years.)What are your plans after selling the practice? Describe any health problem.Which staff members are aware of this appraisal?Do they know the purpose of the appraisal?YesNoHow did you hear about or who referred you to ADS Lovelace and Associates, Inc.?ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 1: Practice/Seller Profile
ADDITIONAL INFORMATION REQUESTED (Copies Only – Data not Returned.)Please advise us immediately if more than one practice is reported on the tax returns or financial statements.Enclosed (Please check-off items provided.)Last three years Tax Returns. (If sole proprietor provide Form 1040 Schedule C, include statement of “otherexpenses”, if corporation provide Form 1120 or 1120S with statement of “other expenses”, partnerships1065).Practice financial statements for the last three years. (Include income statement & balance sheet)Practice interim (year to date) financial statements for the periods:(beginning of tax year through / / )Latest detailed Depreciation Schedule. (if not included with tax return)Previous year’s W-2 forms, identify job description for each employee. (e.g. chairside, hygienist, front office etc.)Current signed Office Lease with any extensions, if you do not own your office.Employment Contracts with associates, partners, and/or employees. (including covenants not to compete)Contracts. (telephone ads, telephone services, service and maintenance agreements, warranties, etc.)Equipment Leases. (postage machine, credit card processor, dental equipment, office equipment,. etc.)First page of monthly Bank Statements since the beginning of the current year.Accounts Receivable aging Report.Your current fee for service schedule and fee schedules for any reduced fee plans.Photographs of all rooms and exterior of office. (digital photographs may be emailed to Plovelace@gmail.com)Diagram of the office layout – may be hand drawn. (worksheet provided)Office Equipment Inventory List. (recommended to have equipment appraisal from dealer rep., if not availablecomplete worksheet provided)List of items excluded from sale. (worksheet provided)Lien Holder(s) Note(s) – Loans secured by practice assets.Appraisal Fee of 4,500(All information requested must be supplied and completed before appraisal is started)PROFESSIONAL ADVISORSACCOUNTING FIRM:Your Accountant’s Name:Office Address:City:Suite #:State:Zip:Phone Number: Fax Number: E-mail:LAW FIRM:Your Attorney’s Name:Office Address:City:Suite #:State:Zip:Phone Number: Fax Number: E-mail:CONSULTING FIRM:Your Consultant’s Name:Office Address:City:Suite #:State:Zip:Phone Number: Fax Number: E-mail:LANDLORD’S OR LEASING COMPANY’S NAME:Your Leasing Agent’s Name:Office Address:City:Suite #:State:Zip:Phone Number: Fax Number: E-mail:ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 2: Practice/Seller Profile
EDUCATION INFORMATIONInstitutionDegreeDate CompletedUndergraduateDental SchoolGraduate School/ResidencySpecialty TrainingBoard Qualified:YesNoBoard Certified:YesNoWhat Professional Organizations do you belong to? ADA State Local( ) Study Group( )How many hours of Continuing Education have you completed in the last 24 months? HoursWhat courses?PRACTICE HISTORYYear began practice in present city:Year began practice in present location:Former OwnerDid you Purchase your practice?YesNo WhenDid you Start your practice?YesNo WhenDo you practice in Another Office? Yes NoWhereIf yes, is it within the subject practice drawing area?YESCurrent Statusof Former OwnerYesNoNO N/AAre you incorporated?Does your corporation own the equipment? Describe:Do you have a partner? Name: Start Date: Do you have a contract with your partner? Do you have a buy-out agreement with your partner? Is there a restrictive covenant?Do you have an associate? Name: Start Date: Compensation Do you have a contract with your associate?Formula: Do you have a buy-out agreement with your associate? Is there a restrictive covenant?Have you had a partner or associate leave within the last 3 years? Explain:Do you share space with another dentist? If yes, please describe thearrangement and include a copy of the agreement.FACILITYDo you Own or Lease your office?Size of the office:OWNSq. Ft.LEASEExpandable:Sq. Ft.Parking: Number of Spaces# Proximity of Parking: Adjacent Parking Garage Free Charge( )Is the office Handicapped Accessible?Yes NoNumber of Treatment Rooms: Doctor # Hygiene # Additional Rooms: Plumbed # Not Plumbed #Treatment Rooms set up for: Right-Handed Delivery Left-Handed DeliveryADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)InterchangeablePage 3: Practice/Seller Profile
FOR LESSEES:Date Lease Entered: Date Lease Expires:Options to Renew: YesNoLength of Option Term: Yrs.Current Total Monthly Rent: Lease Rate for Option Renewal: When does Rent increase? /20 What is New Monthly Rent: What is included in the Monthly Rent? Water Electrical GasBuilding Insurance Security Common Area MaintenanceJanitorialParkingProperty TaxesOther Services Paid for Separately (Not Included in Rent): DescribeIs the Lease Transferable pursuant to its terms?YesNoFOR OWNERS OF OFFICE REAL ESTATE:Do you wish to sell the Real Estate?YesNoSale Price: Current Annual Real Estate Taxes: Current Annual Real Estate Insurance: Average Annual Real Estate Maintenance Costs: Are the above Real Estate Costs paid directly by: PracticePersonallyIs there a current Real Estate Appraisal?YesDate of Appraisal:Appraised Value: Company owned by DentistNoIF NOT SELLING REAL ESTATE:Rental Term in years: yearsMonthly Rental: What is included in the Monthly Rent? Water Electrical Gas JanitorialBuilding Insurance Security Common Area Maintenance ParkingWill you Lease with Option to Purchase? Yes NoWill you owner finance?Yes NoProperty TaxesDescribe:Terms for Owner Financing:PRACTICE INFORMATIONYou currently work days per week.Number of Vacation Holidays CE days / year?You currently work weeks per year.How many days per week do you planon working in the practice after the sale?Year 1Year 2Year 3Year 4Year 5Year 6Year /weekdays/weekIf merging with another practice, how many days per weekdo you plan on working in the practice after the merger?Year 1Year 2Year 3Year 4Year 5Year 6Year /weekdays/weekWhat practice consultants have you used in the past 5 years?When?What were the results?Describe any internal marketing used:Describe any external marketing used:ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 4: Practice/Seller Profile
Number of Patients on Active Hygiene Recall:Number of Active Patients (Patients seen in last 18 months):How did you calculate Patient count:Computer CountIs Appointment Book kept on: ComputerActual Manual CountManually.Number of New Patients seen per month over the last year: Jan Feb Mar Apr May JuneJuly Aug Sept Oct Nov DecAverage # New Patients per Month:Average # of cancellations per Day:Average # Patients seen per day - Dentist:Average # Patients seen per day – Hygienist:How far ahead are you booked? Dentist: weeks Hygienist: weeksAverage # of Hygiene Days per week:What percentage of practice income is from?Fee For Service %(What % FFS is: Cash %,Credit Card %, Indemnity Ins. % Financed %)HMO %PPO %Capitation %Medicaid %Other Reduced Fee Plans %Monthly Payment from Capitation Plans: What PPO PlansWhat PPO Plans cancelled & when?The Office is staffed during these Hours:MTWThFSWThFSWThFSWThFSPatients are seen in the Office during these Hours:MTDoctor’s Hours in the Office:MTHygiene Hours in the Office:MTWhat is balance of Accounts Receivable?What type of Recall System is in use? What is your Collection Ratio?What type of Computer System and Software is in the office?Is Software Assignable?YesNoIs there a Fee for Assignment?YesNoHow much is Transfer Fee: Provide Computer Print-out of Production by Procedure Report by Major Classifications (Proceduresdesignated by ADA Code), otherwise estimate what percentage of your practice ntsFixed Pros.PeriodonticsCosmeticSoft Tissue Management%%%%%%%OperativeOrthodonticsRemovable Pros.EndodonticsOral SurgeryTMJ TreatmentOther%%%%%%%TOTAL100%What procedures do you refer out?ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 5: Practice/Seller Profile
FEE SCHEDULE:Adult Prophy 01110 Gold Inlay 02540 Two Surface Amalgam 02150 Gold/Porcelain Crown 02750 Two Surface Posterior Composite 02386 Core Build-Up Including Pins 02950 Anterior Canal Root Canal 03310 Bicuspid Root Canal 03320 Labial Porcelain Veneer 02962 When was the last fee increase?What percentage was the last fee increase? %Are the fees low, average, or high compared to other practices in your area? LowAt what percentile are your fees compared to other practices in your area? %AverageHighNot Sure .DEMOGRAPHIC AREA:Population of City/TownNumber of Dentists within 5 Mile RadiusMajor Employers in Area:Population of Drawing AreaNumber of New Dentists in 5 Miles Radius in Last 5 YearsDescribe any Major Economic Changes in Drawing Area:Describe any other Demographic Information that may be helpful:PATIENT PROFILE:SocioEconomicAgeZip Code(Six Largest Patient Zips)stUpper%Under 20 Years Old%Zip Code # 1 %Upper Middle%21 - 30 Years Old%Zip Code # 2 %Middle%31 - 40 Years Old%Zip Code # 3 %Lower Middle%41 - 50 Years Old%Zip Code #4 %Low%51 - 60 Years Old%Zip Code #5 %Poverty%61 Years Old%Zip Code #6 %Total100%TotalADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)ndrdththth100%Page 6: Practice/Seller Profile
STAFF INFORMATIONPlease list the following information by Position:PositionName*Gross AnnualSalary orCommissionCommissionRate, ifCommissionedBenefits (pension,health, etc.)Full-Time /Part-TimeYearHiredWill StayAfter SaleIs there aSignedContract?Office ManagerReceptionistBookkeeperAssistant 1Assistant 2Assistant 3Assistant 4Hygienist 1Hygienist 2Hygienist 3Lab TechnicianAssociateAssociateOther*Wages plus Incentives and BonusesWhat employee fringe benefits are provided: Retirement Plan Yes No Amount Contributed Health Insurance Yes No Amount Contributed Other BenefitsDo you employ family members?YesPlease give job descriptions for family membersNoAre they paid?YesNoDescribe any unpaid family member employees, their position, schedule, duties:Does your office currently meet all OSHA & CDC guidelines?YesNoIf No, explainDoes your office comply with provisions of your state dental practice act?YesNoIf No, explainHave you received any disciplinary actions in the past seven years?YesNoIf Yes, explainHave you had any suits filed against you in the past ten years?YesNoIf Yes, explainPlease describe any other information that would be helpful in selling your practice. Include a description of yourpatients and practice philosophy. (If you need additional space, use back of this page.)ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 7: Practice/Seller Profile
ADDITIONAL PRACTICE INFORMATION1. Computer Information:Do you use:a. Electronic insurance filing?YesNob. Send statements daily?YesNoc.YesNod. Treatment pending reports?YesNoe. Recall as part of the program?YesNof.YesNoYesNoInsurance tracking?Computer scheduling?g. Computer maintenance agreement?Monthly?How much is paid annually for computer maintenance agreement?2. Do you use an outside collection agency?YesYesNo No What agency?If so, what is the arrangement?3. Do you see all emergencies the same day?Yes4. Do you currently hold staff meetings? Yes NoIf so, how often? DailyWeeklyNoWho conducts? Dr. Off Mgr. ConsultantMonthly5. Who schedules Operative?Who schedules Hygiene?6. How and when are appointments confirmed:7. Do you have a Staff Training Manual?YesNo8. Do you keep employee o9. Technology: Do you have any of the following?a.b.c.d.e.e.f.g.Computers in the treatment rooms?Intra oral cameras?Digital radiography?Imaging software?Patient charts digitally recorded(paperless)Air abrasion system?Cameras (other)X-Ray units in each room10. Do you have a current Employee Handbook or Personnel Policy Manual?11. Do you perform lab functions in the office? YesYesNoNo What lab do you use?12. Describe any community/civic involvement.13. Lists Hobbies and special interests:14. Are bonuses used as compensation in the practice? Yes NoExplain Bonus plan:15. Do you have a communicator system in the office? Yes NoIf so, what kind?ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 8: Practice/Seller Profile
PRACTICE FINANCIAL DATADEBT AGAINST PRACTICEOriginal Amountof NoteToBalance as ofDateMonthlyPaymentDate NoteBeganLength ofNoteInterestRate* Please include copies of each Note.PRODUCTIONYTD 1/1/To / /YearYearYearDoctors ProductionHygiene ProductionAssociate ProductionTotal Practice ProductionHas the practice gross collections changed significantly in the last three years?YESNOIf Yes, explainI acknowledge and agree that the information provided in this form is intended to be and will bedisclosed to persons (including corporations, partnerships, firms and other individuals) for thepurposes contemplated and that ADS Lovelace and Associates, Inc. shall have no liability for anyclaims, demands or actions arising in connection herewith.To the best of my knowledge, all of the information I have provided is accurate and correct.Please Print Your NameSignatureDateYour Signature is required to process and complete this appraisal.ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 9: Practice/Seller Profile
OFFICE INVENTORY LISTPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.QuantityManufacturer*Approx.Date ofPurchaseDescriptionRECEPTION:Waiting Room ChairsWaiting Room TablesWaiting Room LampsPictures/DecorationsOtherOtherOtherBUSINESS OFFICE:Business Office DeskBusiness Office ChairCopy MachineFile CabinetsTypewriterComputerPrinterSoftwareTelephone SystemCred. Card AuthorizationOtherOtherPRIVATE OFFICE:DeskChairBook m PumpAir DryerOtherOtherLOUNGE:RefrigeratorTable & ChairsMicrowaveOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 10: Practice/Seller Profile
OFFICE INVENTORY LIST – Cont’dPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.QuantityManufacturer*Approx.Date ofPurchaseDescriptionX-RAY EQUIPMENT:Panoramic X-RayFilm ProcessorDeveloping TankDuplicatorOtherOtherTANKS:Nitrous ManifoldSystemTank ValvesOtherOtherOtherOtherLAB:Model TrimmerLatheFurnaceSplash Hood w/ShieldVibratorCasting MachineVacuum Forming UnitPorcelain & Opaque UnitPowder MixerArticulatorsSurveyorPlaster BinsVacuum PumpLab HandpiecesOtherOtherOtherOtherSTERILIZATION:Auto ClaveUltrasonic CleanerOtherOtherOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 11: Practice/Seller Profile
OFFICE INVENTORY LIST – Cont’dPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.If you have additional Treatment Rooms or Hygiene Rooms, you may duplicate the appropriate sheet in order to include a complete listing.QuantityManufacturer*Approx.Date ofPurchaseDescriptionTREATMENT ROOM 1:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorOtherOtherTREATMENT ROOM 2:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorOtherOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 12: Practice/Seller Profile
OFFICE INVENTORY LIST – Cont’dPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.If you have additional Treatment Rooms or Hygiene Rooms, you may duplicate the appropriate sheet in order to include a complete listing.QuantityManufacturer*Approx.Date ofPurchaseDescriptionTREATMENT ROOM 3:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorOtherOtherTREATMENT ROOM 4:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorOtherOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 13: Practice/Seller Profile
OFFICE INVENTORY LIST – Cont’dPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.If you have additional Treatment Rooms or Hygiene Rooms, you may duplicate the appropriate sheet in order to include a complete listing.QuantityManufacturer*Approx.Date ofPurchaseDescriptionHYGIENE ROOM 1:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorCavitronOtherHYGIENE ROOM 2:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorCavitronOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 14: Practice/Seller Profile
OFFICE INVENTORY LIST – Cont’dPLEASE PRINTPROVIDE THE DEPRECIATION SCHEDULE WHICH INCLUDES THE COST AND DATE OF PURCHASE.If you have additional Treatment Rooms or Hygiene Rooms, you may duplicate the appropriate sheet in order to include a complete listing.QuantityManufacturer*Approx.Date ofPurchaseDescriptionHYGIENE ROOM 3:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorCavitronOtherHYGIENE ROOM 4:Patient ChairDental UnitsDoctor’s StoolAssistant’s StoolLightsMobile CartsProphy JetHandpieces:High SpeedLow SpeedOtherCuring LightCabinetsX-Ray UnitsX-Ray View BoxNitrous Flow MeterAmalgamatorCavitronOtherADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 15: Practice/Seller Profile
EXCLUDED ITEMS LISTPlease list all items that will be excluded from the sale.#DESCRIPTION OF ITEM1234567891011121314151617181920ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 16: Practice/Seller Profile
Please Sketch or Attach an Office Layout:ADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 17: Practice/Seller Profile
ADS LOVELACE AND ASSOCIATES, INC.RELEASE FORMI have engaged the services of ADS Lovelace and Associates, Inc. to prepare a valuation ofmy dental practice. It may be necessary for Gretchen Lovelace, M.S., CPM, CFP, PrestonLovelace, J.D., M.S. or one of their representatives to contact you for accounting and taxinformation that is needed in the preparation of the valuation.Please consider this letter authorization for release of my information byto ADS Lovelace and(Accounting Firm)Associates, Inc., and its representatives.Name SignedName PrintedDateADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 18: Practice/Seller Profile
Specialty Practice Supplement for Orthodontic and Oral SurgeryOrthodontic Specialty PracticeTotal number of patients in treatmentComplete banding treatment patientsPartial banding treatment patientsCurrent account balance (contracts receivable)Accounts receivable balance (money past due) Number of patients in treatment no longer paying feesCost of average full treatment: Child AdultNew starts this year as of Jan. 1, New starts in last twelve (12) monthsAverage down payment for records BandingAverage fee per visit Number of patients treated at no chargeNumber of patients in retentionAverage fee per retention: Initial Periodic Number of patients in partial treatment: Adult ChildAverage fee for partial treatment:Adult Child Number of patients in TMJ treatment: Adult ChildAverage fee for TMJ treatment:Adult Child Do you use: Begg % Edgewise % Other % DescribeDescribe technique, banding, etc. most commonly used:What percent of practice is referred from: Other dentists % By patients %Any other information that would be helpful in describing your practiceOral Surgery Specialty PracticeWhat Percent of practice is: Exodontia % Maxillofacial % TMJ % Trauma %Other % DescribeDescribe typical anesthesia technique for in-office surgery:At what hospitals do you have privileges?Describe your referral sources (number, ages, etc.)Any other information that would be helpful in describing your practiceADS LOVELACE AND ASSOCIATES, INC. (Rev. 05/13)Page 19: Practice/Seller Profile
ADS Lovelace and Associates, Inc. Gretchen O. Lovelace, CFP, CPM, MS 2120 Rue Bienvenue Baton Rouge, Louisiana 70809 Phone: 225-927-8015 Cell: 225-892-5135 Fax: 225-927-8115 Email: golovelace@gmail.com Preston L. Lovelace, JD, MS . Describe any health problem. _ Which staff members are aware of this appraisal? .
