Patient First Name *

Patient Last Name *

Phone Number *

Email *

Reason for Teledentistry Video Conference

Medical Conditions:

Allergies/Reactions: Please list all allergies or allergic reactions

Medications: Please list all medications, over the counter and herbal supplements, that you are currently taking

Teledentistry involves the use of electronic communications to enable health care providers to review and share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

-Patient medical records

-Medical images

-Live two-way audio and video

-Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Purpose: The purpose of this form is to get your permission for you to participate in a teledentistry dental care through video and audio conferencing. The teledentistry system allows a dentist to view your records through the internet. The dentist will then make recommendations about your treatment. The dentist may not see you in person.

1. What is a teledentistry consultation?

Teledentistry is a way to provide care for people who do not or cannot go to a dentists office.

2. What happens during teledentistry consultation?

The dentist will review your medical records and/or medical images. The dentist will record what she/he sees. Your medical and dental history and personal health information may be discussed over the video conference call. These discussions will occur through video/phone calls or "store and forward" technology. A teledentistry consultation may require more then one visit.

3. What are the risks, benefits and alternatives?

The benefits of teledentistry include having access to a dentist and additional dental information without having to travel to a dental office or clinic. Teledentistry video conference also reduces the waiting time for patient to see the dentist. A potential risk of teledentistry is that a face-to-face consultation with a dentist may still be necessary after the teledentistry appointment. This could be because of your specific medical or dental condition or for other reasons. Recommendations will be made to you about your future dental care after the teledentistry consultation. These could include recommendations about whether or not to see a dentist in a dental office or dental clinic. A visit to a dental office may be needed in the future even if it is not recommended now. The recommendations may change if more information about your dental needs becomes known. The alternative to teledentistry consultation is a face-to-face visit with a dentist.

4.Confidentiality.

You will be provided with a separate document, which describes how your private information will be handled. This is known as the "Notice of Privacy Practices."

5. Rights.

You may choose not to participate in a teledentistry video consultation at any time before and/or during the consultation. If you decide not to participate, it will not affect your right to future care or treatment. You have the option to seek dental consultation or treatment in a dental office at any time before or after the teledentistry consultation.

Click on the hyperlink to obtain a copy of the Notice of Privacy Practices

The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain patient consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal dental records. We may have indirect treatment relationships with you (such as laboratories that only interact with doctors, not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You may have a right to review your privacy notice, to request restrictions and revoke consent in writing, after you have reviewed our privacy notice.

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