Teledentistry Informed Consent Form

Patient Information

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

Nature of Teledentistry Services

I understand that teledentistry involves the use of electronic communications (video, audio, and/or photo) to enable dental care providers to share individual patient dental information for the purpose of improving patient care delivery.

Terms of Consent

1. I understand that:

   • The same standard of care applies to teledentistry as in-person dental visits
   • Laws protecting confidentiality of medical information apply to teledentistry
   • I have the right to withhold or withdraw my consent at any time

2. I acknowledge that:

   • Teledentistry has limitations and risks, including:
     • Possible delays due to technical difficulties
     • Information transmission quality may impact assessment accuracy
     • In rare cases, security protocols could fail

3. I agree to:

   • Provide accurate and complete information about my health condition
   • Use a secure internet connection
   • Be in a private location during the virtual consultation

Emergency Protocols

I understand that teledentistry is not for dental emergencies. For emergencies, I should:

• Contact the dental office directly during business hours
• Visit the nearest emergency room after hours
• Call 911 for severe emergencies

Financial Responsibility

I understand that I am responsible for any applicable fees associated with teledentistry services, and insurance coverage may vary.

Signature

Patient/Guardian Signature: _________________ Date: _________ Provider Signature: ______________________ Date: _________