PATIENT AGREEMENT FOR DENTAL SERVICES
EFFECTIVE DATE: January 15, 2026
By scheduling an appointment, receiving treatment, or using our services, you (“Patient,” “you,” “your”) agree to be bound by these Terms and Conditions. If you do not agree to these terms, please do not use our services.
Shan Dental provides comprehensive dental care, including but not limited to:
● Preventive dental services (cleanings, examinations, fluoride treatments)
● Restorative dentistry (fillings, crowns, bridges)
● Periodontal therapy and maintenance
● Oral surgery and extractions
● Cosmetic dentistry procedures
● Emergency dental care
● Orthodontic consultations and referrals
MEDICAL HISTORY
● Provide a complete and accurate medical and dental history
● Inform us of any changes to your health status, medications, or allergies
● Disclose all current and previous dental treatments
APPOINTMENTS
● Arrive on time for scheduled appointments
● Provide a 24-hour notice for cancellations or rescheduling
● Cancellation Policy: Late cancellations or no-shows may result in charges
PAYMENT OBLIGATIONS
● Payment is due at the time of service unless prior arrangements are made
● You are responsible for all charges, regardless of insurance coverage
● Collections: Unpaid balances may be referred to collection agencies
COMPLIANCE WITH TREATMENT
● Follow post-treatment instructions and home care recommendations
● Attend recommended follow-up appointments
● Maintain proper oral hygiene as instructed
PAYMENT METHODS We accept cash, checks, credit cards, and approved financing options.
INSURANCE
● We will assist with insurance claim processing as a courtesy
● You are responsible for understanding your coverage and limitations
● Assignment of Benefits: You may assign insurance benefits to our practice
● Coordination of Benefits: You are responsible for coordinating multiple insurance plans
INFORMED CONSENT
● All treatment options, risks, benefits, and alternatives will be explained
● You have the right to refuse or accept any recommended treatment
● Consent Forms: Separate consent forms may be required for specific procedures
DENTAL RECORDS
● We maintain comprehensive dental records in accordance with professional standards and guidelines.
● Record Retention: Records will be maintained for seven (7) years after the last treatment
● Record Requests: Charges may apply for copies of records and radiographs
STANDARD OF CARE We provide dental care in accordance with accepted professional standards. However, we cannot guarantee specific outcomes or results.
Emergency Care: For dental emergencies outside office hours, please contact our emergency line. For life-threatening emergencies, call 911.
REFERRALS We may refer you to specialists when appropriate. You are responsible for scheduling and paying for specialist care.
HIPAA COMPLIANCE Your dental health information is protected under our HIPAA Privacy Policy, which is incorporated by reference into these Terms and Conditions.
COMMUNICATION PREFERENCES
● We may contact you via phone, email, or text to remind you of appointments and follow up on your treatment.
● You may opt out of electronic communications at any time
● Marketing Communications: Separate consent is required for marketing purposes
WEBSITE USAGE Our website is for informational purposes only and does not constitute medical advice.
PATIENT PORTAL
● Access to your dental records and account information through our secure patient portal
● You are responsible for maintaining login credentials and notifying us of unauthorized access.
TELEHEALTH SERVICES When available, telehealth consultations are subject to additional terms and limitations.
GOVERNING LAW These Terms and Conditions are governed by the laws of the State of Texas.
DISPUTE RESOLUTION Any disputes arising from these terms will be resolved through:
1. Direct negotiation with practice management
2. Mediation through a mutually agreed-upon mediator
3. Binding arbitration if mediation fails
VENUE Any legal proceedings will be conducted in the appropriate courts of Katy, Texas.
CHANGES TO TERMS We reserve the right to modify these Terms and Conditions at any time. Updated terms will be posted in our office and on our website.
NOTIFICATION: Material changes will be communicated through written notice or electronic communication.
CONTINUED USE Your continued use of our services after changes constitutes acceptance of the updated terms.
If any provision of these Terms and Conditions is found to be unenforceable, the remaining provisions shall remain in full force and effect.
For questions regarding these Terms and Conditions, contact:
Shan Dental
6300 FM 1463 Suite 150, Katy, TX 77494, United States
Phone: (346) 866-1011
ACKNOWLEDGMENT By using our services, you acknowledge that you have read, understood, and agree to be bound by these Terms and Conditions and our HIPAA Privacy Policy.
