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Add up to 2 additional satellite offices. Please contact a DPT representative if more than 2 satellite offices.
Please complete the linked form (which may also have been provided by your Transitions Consultant).
For the time fields below, please leave them blank if the practice is closed or does not see patients on those days.
Please report or use your best efforts to estimate the percentages of each of the following new patient sources.
Please use your best efforts to estimate the percentages of each of the following payment types.
Please add up to 30 practice employees. If more than 30 employees, please contact DPT representative.
Please estimate annual insurance premiums you pay through the practice:
If you would prefer to mail or fax the form below, please click here to download it.
Please read the following Confidentiality Agreement. By completing the form below and clicking “Agree and Submit”, you agree to the terms and conditions of the Confidentiality Agreement.
This CONFIDENTIALITY AGREEMENT (“Agreement”) is entered into as of the date of submission set forth below (“Submission Date”), by and between the undersigned (the “Receiving Party”) and the Henry Schein Dental Practice Transitions entity set forth immediately below (“HSDPT”). If any one of the practice or associateship opportunities subject of this Agreement is or will be found in (or is reasonably expected to be found in) California, the HSDPT party to this Agreement shall be Henry Schein DPT, Inc., a Wisconsin corporation. Otherwise, the HSDPT party to this Agreement shall be Henry Schein Financial Services, LLC, a Delaware limited liability company.
