Contact Name: (required)
Contact Email:(required)
Formal name of business: (required)
DBA:
Main Business Address:
Name of owner/s:
Name:
% ownership:
Did you start the business?
YesNo
Number of years in business:
Same ownership?
If no, name of previous owner/Practice:
Number of locations/offices?
Full-time:
Part-time:
Number of current employees (including owner):
Audiologists/Licensed Dispenser:
Other Staff:
What is the size of your database:
How many active patients:
Are you currently using a computerized/automated CRM system? YesNo
If so, which one?
Does any person or entity have a ‘Right to First Refusal’ (ROFR) for the purchase of your practice (please explain)?
Annual Sales: Under $250k$250k - $500k$500 +
