Telehealth Services Consent Form for Orthodontic Treatment

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: _____________________

Nature of Telehealth Services

I understand that telehealth in orthodontics involves using electronic communications to enable my orthodontist to monitor my treatment progress and provide certain aspects of care remotely. I acknowledge that:

• Telehealth visits will be conducted through HIPAA-compliant video conferencing platforms
• Photos and videos of my teeth/appliances may be requested and shared electronically
• Not all orthodontic conditions can be addressed through telehealth

Benefits and Limitations

Benefits:

• Reduced in-person visits
• Convenient monitoring of treatment progress
• Timely communication with orthodontic team

Limitations:

• Physical examination cannot be performed remotely
• Technical difficulties may disrupt appointments
• Emergency situations require in-person evaluation

Privacy and Security

I understand that:

• Electronic communication carries inherent privacy risks
• The practice uses secure, encrypted platforms for telehealth services
• My health information is protected under HIPAA regulations

Patient Responsibilities

I agree to:

• Provide accurate and clear photos/videos when requested
• Attend virtual appointments in a private, well-lit location
• Have necessary orthodontic supplies available during sessions
• Report any emergencies or significant concerns promptly

Consent

I have read and understand this consent form and agree to participate in orthodontic telehealth services.

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