Practice Buyer Registration Form

Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Please provide a personal phone number (not a work number).
Address*

Street Address

Street Address Line 2

City

Zip Code
State*
Professional Title*

ODOMDOpticianStudentPrivate EquityOther
Optometry/Medical School You Graduated From*
School Graduated - NA

Check here if not applicable
Date Optometry Degree Received (or to be received)*
MM/YYYY
Date Degree Received - NA

Check here if not applicable
Clinical License Number*
Clinical License Number - NA

Check here if not applicable
State(s) Licensed ⓘ*
Select all that apply or N/A if not applicable
State(s) Licensed
State(s) Licensed*
State Licensed - NA

Check here if not applicable
Specialty Training or Qualifications (include date(s) of completion)
For example: Low Vision, Laser Surgeon, Sports Vision, etc.....
Number of Years Actively Practicing*
List all US States you are interested in purchasing a practice ⓘ*
To select multiple, hold Ctrl on Windows and Command on Macs
Cities, counties, or general areas you are interested in buying a practice?
Are there any unsatisfied judgments against you, your clinical license, or a business you have owned?*

YesNo
What do you estimate is your current credit score?*
What do you estimate is your current credit score?*
How much liquidity do you have (money between cash, checking, and savings accounts)?
Answering this question will enable you access to private listings and help us pair you with the best lenders to get you approved for financing.
Approximately how many patients do you see per 8 hour day?*
What type of practice are you looking to buy?*

Optometry PracticeOphthalmology PracticeLasikIncludes Optical RetailFranchiseIncludes Real EstateOther
If you selected other above, please explain*
Reason for desire to purchase:
Are you also interested in starting a practice?*

YesNo
Do you currently own or have you ever owned a practice?*

YesNo
Listing Reference # ⓘ
LISTING REFERENCE # - if you are inquiring about a specific active listing you must select at least one option below, otherwise we won't know to follow-up with you.
To select multiple listings, hold down CTRL/Command while selecting.
How did you hear about us?
Anything else you'd like to convey? ⓘ
Should be Empty:

N/A
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

AL
AK
AR
AZ
CA
CO
CT
DC
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