Telehealth Consultation Consent Form for Endodontic Services

Patient Information

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

Consent for Telehealth Services

I, _________________________, consent to participate in telehealth consultations with [Practice Name] for endodontic services. I understand that:

Nature of Telehealth Services

• Telehealth involves using electronic communications to enable healthcare providers to share individual patient medical information for diagnosis, therapy, follow-up, and/or education
• The telehealth consultation will be conducted through HIPAA-compliant video conferencing software
• There are potential risks and benefits associated with telehealth

Limitations and Risks

1. Information transmitted may not be sufficient to allow for appropriate clinical decision making
2. Delays in evaluation and treatment could occur due to technical difficulties
3. Security protocols could fail, causing a breach of privacy of personal medical information
4. A lack of access to complete medical records may result in adverse drug interactions or allergic reactions

Patient Responsibilities

• Provide accurate and complete medical history
• Ensure a stable internet connection
• Be present in a private, well-lit location during the consultation
• Have necessary dental images available if previously requested

Emergency Protocols

In case of an emergency during the telehealth consultation, my emergency contact is: Name: _________________________ Phone: ___________________

Acknowledgment

I understand that:

• I can decline telehealth services at any time
• All existing confidentiality protections apply
• I have access to all medical information transmitted during telehealth consultations

Patient Signature: _________________ Date: _______________ Provider Signature: ________________ Date: _______________