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COMPLETE THIS PORTION:
Date:
Buyer:
Seller:
Valuation:

BUYER COMPLETE THIS PORTION:
Name:
Mailing Address:

Telephone:
 Fax:
Best Time to Call:
 Email: 
SELLER COMPLETE THIS PORTION:
Type of Practice:
Gross Income of Practice Desired:
Down Payment Available without Borrow:
Area of Interest (City/State):
Where are you licensed?
From which school did you graduate? Year?
Do you have management experience?
Comments:

VALUATION COMPLETE THIS PORTION:
Type of Practice:
Gross Income of Practice:
Do you own or lease your Real Estate?
How many doctors work at your practice?
What is the reason for the practice valuation?

Please fax this form to (912) 634-9508, or call us at your convenience, to have a confidential discussion regarding your individual needs.