Teledentistry Consent Form

1. Patient Information

2. Purpose of Teledentistry

I understand that teledentistry involves the use of secure electronic communications to allow dental providers at different locations to share my health information for diagnosis, consultation, treatment, education, and ongoing care.

3. Nature of Services

I acknowledge that teledentistry consultations may include:

• Real-time video visits
• Secure transmission of photographs, radiographs, and reports
• Review of remote monitoring data or mobile app information

I understand that in-office evaluation may be required if my condition cannot be adequately assessed remotely, and that emergency conditions require immediate in-person care.

4. Benefits and Risks

Benefits: Improved access, reduced travel, convenience, and scheduling flexibility.

Risks: Delays due to technical issues, incomplete clinical information compared to in-office exams, and potential unauthorized access despite encryption safeguards.

5. Privacy and Security

Your Smile Partners PLLC uses HIPAA-compliant platforms and encryption protocols to protect my information. I understand no system is 100% secure.

6. Patient Responsibilities

I agree to provide accurate medical history, ensure a private setting for sessions, test my equipment, and promptly report technical issues.

7. Financial Responsibility

I understand insurance may cover teledentistry but that I am responsible for applicable co-payments, deductibles, and uncovered charges.

8. Consent to Treatment

I voluntarily consent to receive teledentistry services from Your Smile Partners PLLC and understand I may withdraw consent at any time by notifying the practice.

9. Acknowledgment and Signature

If the patient is a minor or unable to sign: