The dental care providers in this system include: Griffith Family Dental,
Dental Professional - Name (s): Dr. Amy Griffith and/or Dr. Paul Griffth
Dental Professional License Category: DDS
Office Address: 1565 Hollenbeck Avenue Ste 116, Sunnyvale, CA 94087 (note that teledentistry may occur at alternative locations at this time)
Dentist Telephone: 408-234-4035
The teledentistry system allows a dentist to view your records through the internet. The dentist will then make recommendations about your treatment. The dentist may not see you in person.
Teledentistry is the use of video conferencing to enable dental providers at a different location to provide dental care treatment to you and/or consult with you and your dental care provider about your dental care options and decisions. Teledentistry consultations are not the same as direct patient/dentistry provider visits, as you will not be in the same location as the consulting provider. Teledentistry uses electronic dental records such as electronic versions of X-rays, photographs, recordings of the condition of your teeth, health and other history information. These records are reviewed at a later time. These records or other electronic communications are known as “store and forward” records. The goal of the teledentistry system is to have the dentist create recommendations for you for dental care. Teledentistry allows Griffith Family Dental to provide services to you that may otherwise require you to travel long distances or leave “shelter in place” or quarantine orders. Your participation in any teledentistry consultation is completely voluntary.

By signing this form, you are acknowledging that you understand the following: Details of your medical and dental history, including but not limited to, images, x-rays and tests may be shared electronically and discussed with the consulting provider. A virtual physical examination may take place. Non-medical personnel may be present to assist in operating video conferencing equipment. Video, audio, and/or photo recordings may be taken during the procedure to aid in documenting the progress of your treatment. The responsibility of the consulting provider regarding your health/dental care will terminate upon conclusion of the teleconference. Your provider as well as the consulting provider may keep a record of the consultation.

The dentist may examine your mouth and collect electronic dental records. That person will record what she/he sees. Your medical and dental history and personal health information may be discussed with other health professionals. These discussions will occur through phone calls or “store and forward” technology. A teledentistry consultation may require more than one visit. A potential risk of teledentistry is that a face-to-face consultation with a dentist may still be necessary after the teledentistry appointment. This could be because of your specific medical or dental condition or for other reasons. Information provided could include recommendations about whether or not to see a dentist in a dental office or dental clinic. A visit to a dental office may be needed in the future even if it is not recommended now. The recommendations may change if more information about your dental needs becomes known. The alternative to teledentistry consultation is a face-to-face visit with a dentist.

By signing this form, you are acknowledging that you understand the following: Despite our best efforts to protect the privacy of patient information, security protocol could fail causing a breach of privacy of personal medical/dental information. Information provided by teledentistry to the consulting provider may be insufficient to allow for treatment and general medical/dental care decisions to be made. Delays in medical/dental evaluation and treatment may occur due to failures of the electronic equipment.

By signing this form, you are consenting to participate in a teledentistry consultation. You are acknowledging that you have read and understand the provisions in this form. If you are unable to read, you are acknowledging that your health/dental care provider has read this form to you. You are acknowledging that your health/dental care provider has explained to you how teledentistry video conferencing works. My dental care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I agree to have records, including electronic versions of X-rays, photographs, charting of conditions and health and other history information, collected from me and shared and used in this study as described in this consent form. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have requested and authorized.