Consulting Questionnaire

Name
First Last
Email
Phone
Practice Name
Practice Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
# of Years under current owner
How many owners are there?
List doctors and Percentage of Ownership
Click + to add additional doctors
Owner Percentage
Basis of accounting
List any practice specialties
Click all that apply
- Specialty Contact Lens Fitting
- Low Vision
- Pediatric / Vision Therapy
- Myopia Control/ Ortho-K
- Sports Vision
- Other

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FEES
List Usual and Customary (ie self-pay) fees
List fees for: Comprehensive exam new/ Comprehensive exam established/ Intermediate exam new/ Intermediate exam established/ Contact Lens fitting fee - standard (soft sphere)/ Contact Lens fitting fee - speciality (ie toric, bifocal, scleral, etc). Click + to enter each new fee
Service (U&C) Fee Click + to add service
When was the last time exam fees were increased?
Comments - Fees
Optional

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MANAGED CARE
List managed care plans that represent 10% or more of practice revenue
Examples: Davis Vision, Eyemed, VSP, etc. Click + to add each plan.
Vision Plan % of Revenue
Comments - Third Party
Optional

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OFFICE SPACE
Description of office space
Click all that apply
- rented
- owned by practice owner(s)
- mall
- free standing building
- professional building condominium
- commercial strip center
- sub-lease corporate (side by side)
- Other
List lease expiration date and discuss any renewal or transfer options
Owner owns building
Is rent at fair market value?
What would you consider to be fair market value rent for this location?
List annual FMV rent, including common area maintenance, taxes, and property insurance. (Fair market rent values can be determined from local commercial real estate brokers or asking neighboring businesses.)
Number of years at current location
Please enter a number from 0 to 100.
Square Footage of office
Please enter a number from 200 to 10000.
Square footage of optical dispensary
Please enter a number from 0 to 5000.
Comments - Office Space
Include discussion of surroundings, parking, road access, and accessibility.

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HOURS
List office hours
Click + to add each day Monday through Sunday
Day of Week Office Hours
Comments - Office Hours
Optional

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INVENTORY
Number of frames on hand
Average wholesale cost per frame
Average retail price per frame
List current major frame vendors with their respective approximate percentage
Click + to add vendor
Frame vendor Percentage of frame inventory
List current major contact lens vendors with their respective usage and inventory amounts
Click + to add vendor
Contact Lens vendor Percentage of Usage Dollar amount of inventory
Comments - Inventory
Optional

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RECALL AND SCHEDULING

Owner	Percentage

Service	(U&C) Fee Click + to add service

Vision Plan	% of Revenue

Day of Week	Office Hours