Buyer Profile Form 

Name:*
E-mail:*
Phone:*
-
Address:
Date of Birth:*
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Are you an United States Citizen?
Dental School:
Date of Graduation:
Current Career Status?
Date Career Started:
 / 
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My Specialty is:*
I am Here as a(n):*
My Timeline to Buy/Sell*
Best Time To Call:
Additional Comments:
State of Dental License:
License Number:
Graduate School Attended:
Graduation Date:
Degree:
Location of Interest
Select All Practice Types you are Interested in:
Select Transition Types you are Interested in:
Date of Transition:
Delivery System Prefred:
Operatories Desired :
Amount of Annual Collections:
Desired Annual Income:
Preference for Patient Payment Type:
Can You Relocate?
List All Cities of Preference for your Practice:

Do you require any reasonable accommodations in order to perform the essential functions of the position for which you are considering?

Do you currently have any infectious diseases that ethically you feel should be disclosed to potential patients?

Do you have an Accountant?

Do you have an Insurance Agent for Life & Disability?

Electronic Signature

Legal Name:*
Date Signed:*
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Dentcetera Terms & Conditions: 

* By submitting this electronic form to Dentcetera, I agree not to disclose the name or circumstances of any parties introduced to me by Dentcetera . I also agree that all information provided by Dentcetera is confidential and agree not to disclose to anyone or make copies of any of the information, ideas, procedures, programs, concepts, contract and/or other data conveyed and entrusted to me without the prior written consent of Dentcetera. In addition, I also agree that, upon request by Dentcetera, any projections, calculations, word descriptions, and tangible material given to me will be immediately returned to Dentcetera.