Shea Practice Transitions

6750 France Avenue South, Suite 114
Edina, MN 55435

Twin Cities: 952.920.9411
toll-free: 877.275.2727
fax: 952.920.0794
e-mail: sheainfo@sheatransitions.com

Please complete the Confidentiality Agreement and Buyer's Questionnaire below, and a representative from our organization will be in contact with you. All information is kept strictly confidential. (Please complete all fields).

Purpose of inquiry:
Comments:

CONFIDENTIALITY AGREEMENT
AND
REPRESENTATION DISCLOSURE
(“Agreement”)

© Copyright Shea Practice Transitions, P.A., 2004

This Agreement is made this by Shea Practice Transitions, P.A., a Minnesota Corporation, with its place of business at 6750 France Avenue South, Edina, Minnesota (“SPT”), clients of SPT (“SPT Clients”), and , (please complete name, including middle initial and D.D.S. or D.M.D.), who has an interest in acquiring, 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 under professional privilege, without SPT and SPT Client’s prior written permission. Buyer agrees to use the same degree of care to protect the confidentiality of the Confidential Information and to prevent its unauthorized use or dissemination as Buyer would use to protect Buyer’s own confidential information of a similar nature.

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, Buyer shall return all Confidential Information to SPT or SPT Clients and 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 expires three (3) years from the date of the disclosure.

5. Equitable Relief. 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 it would have no adequate remedy at law. SPT 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 in law or equity.

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 both 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 Buyer’s 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.

SPT:
Kevin A. Shea, President

BUYER:

(Enter full name and D.D.S. or D.M.D.)

Electronic Signature:
By checking this box, Buyer hereby consents and agrees to all the terms and conditions of this Agreement. Buyer agrees that such action is an electronic substitute for Buyer’s signature on this Agreement. Buyer agrees to sign an identical copy of this Agreement if so requested by SPT.

BUYER'S QUESTIONNAIRE

Thank you for allowing us to assist you with finding a dental practice opportunity for you. Hopefully we will be successful in locating your ideal practice. The following is some information that will help us in achieving that goal (please complete all areas and be assured that this information will be held in strict confidence, provided only to potential sellers and employers):

Date:

Full name:

Address:(where do you want the information to be sent?)

Address 2:

City, State, Zip:

Home phone:

Office phone:

May we contact you there?

yes no

Cell phone:

Email:

Can you receive documents via your email?

yes no

Fax:
(if applicable)

Preferred method of contact:

phone email

Preferred time of contact:

morning afternoon evening

Graduation year:

Dental School:

Dental license number:
(if applicable)

Do you have a current CV or resume?

yes no
if yes, please send as attachment to sheainfo@sheatransitions.com

Clinically, what procedures are you proficient in?

Endo	Rotary Endo	Cosmetic
Ortho	Pedo	Oral Surgery
Implants	Perio	TMJ

Which areas of dentistry do you prefer the most?

Briefly describe your ideal practice:

What is your preferred location(s)?

What are your annual income expectations or goals?

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

What is your timeframe to own a practice?

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

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

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

Have you talked to other brokers? If so, please specify

What did you like or dislike about other brokers?

Have you prepared a household budget (e.g. mortgage/rent, student loan payments, car payments)?

Do you have life insurance?

yes no

If so, how much?

Do you have disability insurance?

yes no

If so, how much?

Have you prepared a net worth statement?

yes no

What are your hobbies or other interests?

Please list at least two dental labs whom have performed work for you (include telephone number and lab tech or contact person).

1.
2.

Please list at least two references whom we can contact (include name and telephone number):

1.
2.

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

6750 France Avenue South, Suite 114 Edina, MN 55435 ph: 952.920.9411 fx: 952.920.0794 sheainfo@sheatransitions.com