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Buyer Profile Info
Buyer Profile Info
Please complete the following profile so we can better understand your preferences for practice opportunities. We can also notify you of practice opportunities as they become available.
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General
First Name
*
Last Name
*
Email
*
Date of Birth
Month
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1931
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Are you a US citizen?
*
Yes
No
What is your current INS status?
Home Phone Number
Will your Spouse be the primary contact?
Yes
No
Spouse's Full Name
Spouse's Email
Spouse's Mobile Phone
What is your current career status?
Student
Resident/Graduate Student
Military Doctor
Associate
Owner/Partner
Other
How many years have you been in the above career status?
Medical School Attended
Graduation Year
State of Medical License
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
License Number
Residency/Graduate School Attended
Graduation Year
Degree
Practice Criteria
What Regions in Texas are of most interest to you? (Please check all that apply.)
*
Austin and Hill Country
Central Texas
Dallas and Suburbs
East Texas
El Paso Area
Fort Worth and Suburbs
Houston and Suburbs
Panhandle
San Antonio Area
South Texas
West Texas
What practice types are you interested in? (Please check all that apply.)
*
Dermatology
ENT/Otolaryngologist
Family Medicine
General Surgery
Internal Medicine
OB/GYN
Ophthalmology
Pediatrics
Plastic Surgery
Podiatry
What transition types are you interested in? (Please check all that apply.)
Practice for Sale
Practice Merger
Associateship
Partnership
Solo Group
Sale of Practice-Ready Facility
Sale of Facility Only
Sale of Real Estate Only
Sale of Equipment Only
What is the ideal date for this transition?
MM slash DD slash YYYY
What is the ideal number of exam rooms you want in the facility?
1 to 3
4 to 6
7 or more
What is the ideal amount of annual collections you want for the practice?
Less than $400,000
$400,000 to $600,000
$600,000 to $800,000
$800,000 to $1 Million
$1 Million to $1.2 Million
$1.2 Million to $1.5 Million
$1.5 Million or More
What is your desired annual income?
Less than $100,000
$100,000 to $200,000
$200,000 to $300,000
$300,000 to $400,000
More than $400,000
What is your preference for patient payment type?
Fee for Service
PPO/Insurance
Medicaid
Would you be willing and able to relocate?
Yes
No
What is the furthest commute you would consider?
First Preference of City for Practice
Second Preference of City for Practice
Third Preference of City for Practice
Please indicate any other preferences or criteria you have in selecting the ideal practice opportunity.
Background Questionnaire
Do you require any reasonable accommodations in order to perform the essential functions of the position for which you are considering?
Yes
No
Please explain what accommodations you require:
Do you currently have any infectious diseases that ethically you feel should be disclosed to potential patients?
Yes
No
Please explain:
Have you been the subject of any disciplinary proceedings by the State Medical Board?
Yes
No
If Yes, please explain:
Are there any unsatisfied judgments against you or any business you have owned?
Yes
No
If Yes, please explain:
Have you ever filed for bankruptcy?
Yes
No
If Yes, please explain:
Have you ever been found guilty, entered a plea of "no contest", or been a party to a consent degree with regard to any of the following? (check each box that applies)
Malpractice Claim
Crime involving moral turpitude
Criminal or civil litigation involving substance abuse
Charge of Fraud or Tax-Avoidance with regard to any Federal or State taxes
If yes, please explain: (Malpractice claim)
If yes, please explain: (Crime involving moral turpitude)
If yes, please explains: (Criminal or civil litigation involving substance abuse)
If Yes, please explain: (Charge of Fraud or Tax-Avoidance with regard to any Federal or State taxes)
Professional Advisers
Are you working with another Broker?
Yes
No
What is the Broker's name?
Which lenders have you already contacted about financing?
Do you have an Accountant?
Yes
No
What is the Accountant's name(s)?
Do you have an Attorney?
Yes
No
What is the Attorney's name(s)?
Do you have an Insurance Agent for Life & Disability?
Yes
No
What is the Insurance Agent's name(s)?
Electronic Signature
Full Legal Name
*
By checking the Electronic Signature box, I agree that to the best of my knowledge, all of the information provided is accurate and correct. I also agree that such action is an electronic substitute for my signature on this form. I also acknowledge that the information provided in this form is intended to be and will be disclosed to persons (including corporations, partnerships, firms, lenders and other individuals) for the purposes contemplated and that ADS Watson, Brown & Associates shall have no liability for any claims, demands or action arising in connection herewith.
*
Electronic Signature
Email Notifications
Please email when new practice opportunities become available.
Please enroll me for the free e-newsletter, ADS Insider.
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