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

Optometry/Medical School You Graduated From

School Graduated - NA

Date Optometry Degree Received (or to be received)

MM/YYYY

Date Degree Received - NA

Clinical License Number

Clinical License Number - NA

State(s) Licensed ⓘ

Select all that apply or N/A if not applicable

State(s) Licensed

State(s) Licensed

State Licensed - NA

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?

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?

If you selected other above, please explain

Reason for desire to purchase:

Are you also interested in starting a practice?

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

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? ⓘ

N/A
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