| REQUESTED
BY: |
Name |
_________________________________ |
|
DATE: |
| |
Address |
_________________________________ |
|
___________ |
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|
_________________________________ |
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|
_________________________________ |
SERVICE REQUIRED: |
| |
Phone |
(0____)_______________________ |
[
] Standard - 10 days*; 2
copies of report by Express
Post |
| |
Email |
_____________________________ |
|
| |
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|
[
] Priority – 2 days*; 1 copy
by email; 2 copies by
Express Post |
| PRACTICE: |
Name |
_________________________________ |
|
| |
Address |
_________________________________
|
(*
we will advise if these times are not
possible due to other commitments) |
| |
|
_________________________________
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|
_________________________________ |
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| LOCATION: |
[ ] Office
building or professional suite |
OFFICE SIZE: |
________M2 |
| |
[ ] Shop
with windows obscured |
|
___Cons rms |
| |
[ ] Shop
with window displays |
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[ ] Shop
in shopping mall (dispensing) |
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[ ] Non-dispensing
adjoining optical shop |
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| PREMISES: |
[ ] Leased
from a landlord |
LEASE EXP: |
___/___/___ |
| |
[ ] Owned
by practitioner(s) or associated entity |
RENT REVIEW: |
___/___/___ |
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| GROSS FEES: |
(Last Year) |
To June _________ |
$___________ |
|
| (Incl value of
trade |
(Prev Year) |
To June _________ |
$___________ |
|
| $'s - eg: Bartercard) |
(Next Prev Yr) |
To June _________ |
$___________ |
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| NETT INCOME: |
Annual
Nett Income of owners (incl owner wages) |
$___________ |
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| |
Plus
Tax-Deductable Items of a more personal nature: |
|
| |
- use
of Motor Vehicle |
$___________ |
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- Interest
paid by practice (total) |
$___________ |
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- Self
education & travel |
$___________ |
|
| |
- Superannuation
for owner(s) |
$___________ |
|
| |
- Adjustment
for market rent |
(+/-)$_______ |
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- Trade
dollars used for "personal" |
$___________ |
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- Other:______________________________________ |
$___________ |
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| PATIENTS P.A.: |
Number
of initial consultations (10900 equiv fee) |
|
| |
(Last Year) |
To June _________ |
____________ |
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| |
(Prev Year) |
To June _________ |
____________ |
|
| |
(Next Prev Yr) |
To June _________ |
____________ |
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| ASSETS: |
Book value
of Fixtures & Fittings |
$___________ |
|
| |
Book value
of Machines & Equipment |
$___________ |
|
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Inventory
at Nett Cost |
$___________ |
|
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Accounts
Receivable (owed by patients) |
$___________ |
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| RENT P.A.: |
$___________ |
COST OF GOODS SUPPLIED LAST YEAR: |
$__________ |
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| STAFF LEVELS: |
Show
number of staff &
owner(s) involved for each occupation, then the
equivalent |
| |
full-time
persons they represent (eg 1 day = 0.2 equiv F.T.) |
| |
|
|
Total Persons |
Equiv F.T. |
| |
Receptionists |
___________ |
___________ |
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Administration |
___________ |
___________ |
| |
Optical
Assistants |
___________ |
___________ |
| |
Orthoptists |
___________ |
___________ |
| |
Optical
Dispensers |
___________ |
___________ |
| |
Optical
Mechanics |
___________ |
___________ |
| |
Optometrists |
___________ |
___________ |
| |
|
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| OWNER |
Of this, how much
time is spent by owner(s) working in the practice |
Equiv F.T. |
| OPTOMETRISTS: |
(the equivalent
full-time persons they represent - eg 1 day =0.2 equiv F.T.) |
___________ |
| |
|
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| EMPLOYED |
Total Income Paid
to ALL Employed Optometrists |
|
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| OPTOMETRISTS: |
(incl locums) |
|
$___________ |
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| PATIENTS: |
% New vs Returning |
_____% New |
% Female |
_____% |
| |
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| MISCELLANEOUS: |
Useage
of patients' "OWN FRAMES" |
______%
of all frames |
| |
Fees Charged
(compared to "Eye Talk" suggestions) |
+/-_____%
vs Eye Talk |
| |
Recall
System being used |
[ ] None |
[ ] Postcard |
| |
|
|
[ ] Letter |
[ ] Telephone |
| |
Recall
Response Rate (within 3 months of notification) |
__________% |
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NOTES:
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| The resulting
Practice Report will be an independent opinion based upon
information supplied to us, and exclusively for the use |
| of our client.
Therefore, please be sure to COMPLETE ALL AREAS
OF THIS QUESTIONNAIRE as accurately as possible. |
| The report should
not be construed as a valuation, but as an opinion for the clients
information. |
