Confidentiality Agreement

Please complete this two-part Confidentiality Agreement/Buyer Questionnaire if you are interested in having Shea Practice Transitions assist you with your practice transition.

PART 1

CONFIDENTIALITY AGREEMENT AND REPRESENTATION DISCLOSURE

("Agreement")

 

Please leave this field empty.

 

This Agreement is made on this date (required): , by Shea Practice Transitions, P.A., a Minnesota Corporation, with its place of business at 6750 France Avenue South, Suite #114, Edina, Minnesota ("SPT"), clients of SPT ("SPT Clients"), and ,
D.D.S.D.M.D.
, who has an interest in purchasing, buying into, or associating with a dental practice ("Buyer").

SPT and SPT Clients possess confidential and/or proprietary information related to a dental
practice that Buyer has shown an interest in, including without limitation financial information,
statements, books, records, and patient information, identity and location of SPT Client's dental
practice, which may be articulated orally or in writing ("Confidential Information").

SPT wishes to disclose such Confidential Information to Buyer, and Buyer wishes to receive such Confidential Information in order to facilitate discussions regarding a possible business
transaction involving Buyer. In consideration of the receipt of certain Confidential Information and the mutual promises made herein, the parties agree as follows:

1. Buyer's Duty to Protect Confidential Information. Buyer shall not disclose the
Confidential Information to any third party other than attorneys and accountants whom are
representing Buyer under professional privilege, without SPT and SPT Client's prior written
permission. Buyer agrees to keep and protect with strict confidentiality, the Confidential
Information and to prevent its unauthorized use or dissemination, except as authorized herein.

2. Buyer's Use of Confidential Information. All Confidential Information remains the
property of SPT or SPT Clients and no licenses or other rights are granted or implied by this
Agreement. Upon request by SPT or SPT Clients, termination or expiration of this Agreement,
and at SPT's sole discretion, Buyer shall return all Confidential Information to SPT or SPT Clients
and/or certify that all copies have been destroyed.

3. Term. This Agreement shall become effective as of the date first set forth above and
shall terminate upon the earlier of (i) written notice of either party of its election, with or
without cause, to terminate this Agreement; or (ii) three (3) years following the effective date.

4. Duration of Duty. Buyer's duty to protect Confidential Information disclosed under this
Agreement remains even after the expiration as further provided herein.

5. Remedies. Buyer agrees and acknowledges that any unauthorized use of Confidential
Information in violation of this Agreement will cause SPT or SPT Clients irreparable injury for
which either may not have any adequate remedy at law. SPT and/or SPT Clients shall therefore
be entitled to immediate injunctive relief prohibiting any violation of this Agreement, in
addition to any other remedies that may be available (to either SPT and/or SPT Clients) in law
or equity, including but not limited to damages, costs, attorneys fees and costs of litigation.

6. No Agency or Partnership. The parties do not intend that this Agreement creates any
agency or partnership between them.

7. Modification. All additions or modifications to this Agreement must be made in writing
and must be signed by all Parties.

8. Governing Law. This Agreement is made under and shall be construed according to the
laws of the State of Minnesota.

9. Disclosure of Representation. Shea Practice Transitions, P.A. is representing its Client(s)
only. Neither Kevin Shea, Ryan Brengman, nor Shea Practice Transitions, P.A. has undertaken or
will undertake to represent Buyer as a broker, as Buyer's attorney for a transaction
contemplated herein, or otherwise. Buyer is encouraged to seek Buyers own professional
assistance, including legal representation, for any transaction contemplated by this Agreement.

This Agreement may be executed in two or more counterparts, each of which shall be deemed
an original for all purposes, and together shall constitute one and the same document. Buyer's
facsimile or electronic signature shall be deemed an original signature.

SPT: Kevin A. Shea, President

BUYER: (By entering your full name and D.D.S. or D.M.D. into this text field and pressing submit, you acknowledge entering this agreement)

 

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PART 2

BUYER'S QUESTIONNAIRE

 

The Purpose of Your Inquiry (required)

Can we correspond with you at this email address? (required)
YesNo

Where would you prefer to be contacted? (required)

What is your preferred method of contact?

Home Address

Can we correspond with you at this address and phone? (required)
YesNo

Office Address

Can we correspond with you at this address and phone? (required)
YesNo

Other Address, if applicable

Can we correspond with you at this address and phone? (required)
YesNo

Do you have a current CV or resume? (required)
YesNo

If so, please upload.

Have any disciplinary actions been filed against you by any state licensing authority (e.g.; Board of Dentistry)? (required)
YesNo

If so, please specify the date and circumstances:

Clinically, what procedures are you proficient in? (required)
EndoOrthoImplantsRotary EndoPedoPerioCosmeticOral SurgeryTMJ

Which areas of dentistry do you prefer the most? (required)

Briefly describe your ideal practice (required):

What is your preferred location(s)? (required)

What are your annual income expectations or goals? (required)

What is the nature of the practice you would like to find (e.g. amalgam-free, all fee-for-service
production, associate buy-in, solo practice sale, buy-out)? (required)

What is your timeframe to own a practice? (required)

Is there anyone else that wll be assisting you with your decision (e.g. spouse, family member
consultant, accountant, attorney)? If so, please specify. (required)

Have you had an opportunity to look at other practices? If so, please specify. (required)

What did you like or dislike about other practices you have seen? (required)

Have you talked to other brokers? If so please specify. (required)

What did you like or dislike about other brokers? (required)

Please list at least two Dental Labs whom have performed work for you (include telephone number and lab tech or contact person):

 



 



 



 



Please list at least two references whom we can contact--including name and telephone number:

 


 


 


 


By checking this box, I certify that the foregoing information is true and accurate to the best
knowledge. I hereby authorize and consent to contacting the references listed above (required).

I agree