Teledentistry Informed Consent for Oral Surgery Consultation

Patient Information

Name: _________________________ Date of Birth: _____________ Phone: _________________________ Email: ___________________

Consent for Teledentistry Services

I, _________________________, hereby consent to participate in teledentistry consultation with Dr. _________________________ and associates of _________________________ Oral Surgery Practice.

Understanding of Service

• I understand that teledentistry involves the use of electronic communications to enable healthcare providers to share individual patient medical information for the purpose of improving patient care delivery.
• The information may be used for diagnosis, therapy, follow-up and/or education.

Acknowledgments

I acknowledge and understand that:

1. The same standard of care applies to a teledentistry consultation as applies to an in-person consultation.
2. The laws that protect privacy and confidentiality of medical information also apply to teledentistry.
3. I have the right to withhold or withdraw my consent to the use of teledentistry at any time.
4. A physical examination may be required before certain prescriptions can be issued.

Limitations and Risks

I understand that:

• Technical difficulties may occur before or during the teledentistry sessions and my appointment may need to be rescheduled.
• In rare cases, security protocols could fail, causing a breach of privacy of personal medical information.
• In some cases, a face-to-face consultation may still be necessary after the teledentistry appointment.

Emergency Protocol

In the event of an emergency during the teledental consultation, my care will be referred to:

Emergency Contact: _________________________ Phone: _________________________

Consent and Signature

I have read and understand the information provided above regarding teledentistry.

Patient Signature: _________________________ Date: _____________

Witness Signature: _________________________ Date: _____________