TeleDentistry Consent

Telemedicine Informed Consent

1. Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your child’s medical or health history and personal health information may be discussed through the use of interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal documents.
2. The telemedicine services you receive from Providers are not intended to replace a primary care dentist relationship or be your permanent dental home. You should seek emergency help or follow-up care when recommended by a Provider or when otherwise needed, and continue to consult with your child’s primary care dentist and other health care professionals as recommended. We may make arrangements for follow-up care either through the Provider, a health systems partner, or other health care providers. If the transmission fails during your telemedicine consultation with a physician, then a member of our customer support team will contact you to help you get reconnected. You will have direct access to customer support services to follow-up on medication reactions, side effects, or other adverse events. Our providers do not dispense or prescribe narcotics. Telemedicine Service is improved access to dental health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but may not be limited to:
   1. In some instances the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.);
   2.  Delays in evaluation or treatment could occur due to failure of the electronic equipment;
   3. In some instances a lack of access to all of your medical records may result in adverse drug reactions or allergic reactions or other judgment errors;
   4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information.
3. By accepting these terms of use you acknowledge that you understand and agree with the following:
4. You understand that you may expect the anticipated benefits from the use of telemedicine in your care, but that no results can be guaranteed or assured;

6. You understand that the laws that protect the privacy and security of health information apply to telemedicine and you have received our privacy practices which describe these protections in more detail;
7. 7. You understand that you are fully responsible for payment; and
8. 8. You understand your Provider, in his or her sole discretion and professional judgment may determine that telemedicine services are not appropriate for some or all of your treatment needs and, accordingly, may elect not to provide telemedicine services to you through the platform.