Buyer/Associate Registration

Personal Information

First Name* Last Name* Title*

DMD DDSStudent

E-mail* Address*

Street Address
Street Address Line 2
City	State
Zip Code	Country

Preferred Phone Number *

Area Code Phone Number

Education

Dental Degree* School Graduation Date* Month Day Year

Specialty*

License #* Issuing State*

Confidentiality Agreement

The person stated above (hereinafter "Prospective Purchaser/Associate") is interested in the possible acquisition of a dental practice in the following states:

States Interested In*

(Note: It is critically important that you check each state you would consider for a practice.)

List the states you're interested in here, separated by commas, using state abbreviations

Prospective Purchaser/Associate acknowledges that Phase II Dental Transitions ("Phase II") shall furnish Prospective Purchaser/Associate with certain confidential and proprietary information pertaining to the practice opportunities, including, but not limited to tax returns, profit and loss statements, fee schedules, employee census, equipment lists, appraisals, leases, etc. In consideration for Phase II providing the aforementioned information, Prospective Purchaser/Associate hereby agrees to the following:

1. That all the information and documentation provided to or disclosed to Prospective Purchaser/Associate are private in nature and shall remain confidential. Prospective Purchaser/Associate agrees not to disclose to any person, firm, or corporation without Owner's express written consent any information or documentation that Prospective Purchaser/Associate shall acquire regarding Owner's dental practice, except to Prospective Purchaser/Associate's bona fide counsel(attorney or accountant). Prospective Purchaser/Associate agrees that its bona fide counsel will maintain the confidentiality of any information as well. Prospective Purchaser/Associate also agrees that the disclosure of any information (including Owner’s intent to sell/hire an associate and practice location) or documentation with respect to the dental practice of Owner would cause Owner irreparable harm and damage. Prospective Purchaser/Associate further agrees that Prospective Purchaser/Associate will hold harmless and indemnify Phase II and Owner in the event of disclosure of any information or documentation respecting Owner's dental practice, except as herein noted.

2. That the information and documentation forwarded to Prospective Purchaser/Associate pertaining to the Owner's practice is to be used solely to assist Prospective Purchaser/Associate in deciding whether to purchase or associate with said practice and will not be used in any other manner for personal or professional benefit. Prospective Purchaser/Associate will comply with current HIPAA - regulations with respect to any documents provided or practice visit.

3. That in the event Prospective Purchaser/Associate decides not to purchase or associate with the abovementioned practice, Prospective Purchaser/Associate will immediately notify Phase II of this decision and will return all documentation without retaining copies or extracts thereof.

4. That Prospective Purchaser/Associate will not directly contact the dental practice Owner, practice employees, or any agents of the practice without Phase II Dental Transitions’ express written consent.

NOTE: YOU ARE SIGNING A LEGALLY BINDING DOCUMENT. BREACH OF CONFIDENTIALITY MAY RESULT IN PURSUIT OF DAMAGES. BY ACCEPTING THIS AGREEMENT, BUYER IS STATING THAT HE/SHE UNDERSTANDS ALL THE TERMS AND CONDITIONS, THE SAME AS IF HE/SHE WAS SIGNING THE AGREEMENT.

I agree to the above terms & conditions