Is your Search Confidential:

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Name (required)

City:

State

Zip

Legal Name of the Practice:

Address:

Dr's Direct Phone:

Email (required)

Office Square Footage:

# of operatories:

Staff:

# of hygienists:

# of Assistants:

# of Front Office Staff:

Fax:

Website:

Referred By

Specialty

Type / Age Range of Patients / Personality of the office?

Technology, Equipment and Computer Software in the Office:

Total Monthly Doctor Production:

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Do You Have a Dental Consultant or Dental Broker You Are Working With?

Are You Working With Any Other Recruiting Firms?

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Procedures Referred Out:

Total Monthly Office Production:

$

Do You Have a Transition Plan? and / or Contingency Plan?

What is the Compensation Structure for the Associate?

Weekly Office Schedule: Hours Of Operation

Describe the Type of Person That You Are Seeking for the Opportunity in Your Practice:

What is Your Ideal Time Frame to Bring in a New Doctor?

Please Tell Us a Little Bit More About Yourself, Such as Where You Went to Dental School, Your Hobbies, Why You Chose Dentistry and Anything Else That Will Help us Match You With Your New Associate.