Medical Practice Valuation Form
Please provide the following details to estimate the value of your medical practice. All fields are required for an accurate assessment.
Practice Name
*
Practice Type
*
Please Select
Solo Practice
Group Practice
Clinic
Specialty Center
Other
Location (City, State)
*
Number of Physicians/Providers
*
Estimated Annual Revenue (USD)
*
Please Select
Under $500,000
$500,000 - $1,000,000
$1,000,001 - $2,500,000
$2,500,001 - $5,000,000
Over $5,000,000
Estimated Annual Expenses (USD)
*
Please Select
Under $250,000
$250,000 - $500,000
$500,001 - $1,000,000
$1,000,001 - $2,000,000
Over $2,000,000
Average Monthly Patient Visits
*
Primary Payer Mix
*
Private Insurance
Medicare
Medicaid
Self-Pay
Other
Years in Operation
*
Does your practice own its real estate or major equipment?
*
Owns Real Estate
Owns Major Equipment Only
Leases All
Estimate Value
Should be Empty: