Secure electronic agreement — fill in, sign, and submit from any device.
PureShield logo
PURESHIELD
Electro-Disinfecting

Medical & Dental Disinfection Service Agreement

Professional electrostatic disinfection for medical & dental practices
(469) 430-6401
info@pureshield360.com
North Dallas, TX
Mon–Thurs 9am–6pm (Office) · Fri–Sun 10am–10pm (Service)
Agreement ID: Version: 1.0 Status: Awaiting Signature

Agreement signed & recorded

This Service Agreement (the “Agreement”) is entered into between PureShield Electro-Disinfecting (“Provider”) and the practice identified below (“Client”) for recurring or one-time electrostatic disinfection services performed at the Client’s medical or dental facility. Please complete the fields, review the terms, and sign electronically below.

1

Practice & Facility Information

2

Scope of Services

Provider will perform professional electrostatic disinfection of the Client’s medical or dental facility using EPA List N, hospital-grade disinfectant applied with Protexus cordless electrostatic sprayers. Each service includes:

  • 360° electrostatic application to exam & treatment rooms, operatories, dental chairs, counters, and equipment surfaces.
  • High-touch points throughout the practice — reception, waiting areas, check-in counters, door & light handles, and restrooms.
  • EPA List N, hospital-grade, bleach-free solution applied at manufacturer-tested dwell times for a fast return-to-service.
  • A proof-of-service log entry the Client may retain for infection-control and compliance records.

Services are a supplement to, and not a replacement for, the Client’s own routine cleaning, instrument sterilization, and OSHA-required infection-control protocols.

3

Practice Size & Pricing

Flat-rate pricing by number of exam or treatment rooms — no per-square-foot guesswork. Select the tier and service frequency that apply.

Small Practice
1–4 Rooms
Up to ~2,000 sq ft
$175
flat / visit
Large Practice
9–12 Rooms
~4,000–6,000 sq ft
$475
flat / visit
Extra-Large
13+ Rooms
6,000+ sq ft
Custom Quote
contact us
One-Time
Weekly
Bi-Weekly
Monthly
Selected Plan
Please select a practice size & frequency
Your Rate
4

Term, Scheduling & Payment

  • Term. This Agreement begins on the Effective Date below. One-time service is a single scheduled visit; recurring service continues on a month-to-month basis until cancelled per Section 5.
  • Scheduling. Service is timed around your patients — after-hours, on closed days, or in between-patient windows — on a mutually agreed schedule.
  • Payment. One-time visits are due upon completion; recurring plans are billed per visit. Accepted methods: credit/debit, digital wallet, Cash App, Zelle, Venmo, and cash (exact amount only).
  • Late Payment. Invoices unpaid within seven (7) days may pause service until the balance is current.
Recurring Service Discounts Best Value

Flat-rate pricing reflects a $35-per-room baseline bundled into one predictable price per visit. Lock in a recurring schedule for a discounted per-visit rate — ask for your custom recurring quote.

Weekly, bi-weekly & monthly plans available at discounted recurring rates.
Priority scheduling and a documented service log on every recurring visit.
5

Cancellation & Rescheduling

  • Either party may cancel this Agreement with fourteen (14) days’ written notice (email accepted).
  • Individual visits may be rescheduled with at least 24 hours’ notice at no charge; same-day cancellations may incur up to 50% of the visit rate.
  • No long-term commitment is required — recurring service continues only while both parties agree.
6

General Terms

  • Access. Client will provide safe, timely access to the facility at the scheduled service time.
  • Safety & Compliance. Provider uses EPA List N disinfectants and OSHA-aligned, ETL-certified equipment, applied by trained technicians following label dwell times, proper PPE, and bloodborne-pathogen awareness.
  • Liability. Provider maintains general liability insurance. Provider is not liable for pre-existing damage, items not disclosed prior to service, or surfaces or equipment sensitive to moisture that were not identified by Client.
  • Personal Property. Client should secure or cover sensitive electronics, charts, instruments, and open supplies prior to each visit.
  • Entire Agreement. This document is the entire agreement between the parties and supersedes prior discussions. Texas law governs.
7

Electronic Signature

Sign to Authorize

Draw your signature or type your name. By signing, you agree to the terms of this Agreement.

Draw
Type
Your signature will appear here
Client Signature
Provider — PureShield Electro-Disinfecting
PureShield
Authorized Representative
Veteran-Owned · North Dallas, TX
(469) 430-6401