PATIENT ACKNOWLEDGEMENT – TELEHEALTH CONSULTATION SERVICES
•Telehealth includes the use of remote communication technology to conduct virtual problem-focused evaluations to help manage oral health concerns and to determine whether immediate in-office dental treatment is required.
•I have been informed that telehealth is an option during the COVID-19 pandemic to evaluate my dental
health concerns, screen for dental emergencies and minimize the risk of virus transmission.

Patient Acknowledgement – Telehealth Consultation Services
•I acknowledge that I wish to receive telehealth consultation services.
•I understand that this telehealth consultation is for the purpose of evaluating dental pain, oral swelling, and / or treatment planning.
•I understand that I may request to refuse or stop telehealth services at any time.
•I understand that if at any time during or after the telehealth consultation I experience a life-threatening condition or medical emergency, I will immediately call 911 or go to the nearest emergency room.
•I understand and accept that a telehealth consultation cannot replace an in-office consultation and I acknowledge that the doctor’s ability to diagnose my condition could be limited by this technology. I further understand, acknowledge and accept that a virtual evaluation may not reveal conditions that might otherwise be discovered during an office visit.
•I agree to provide detailed and accurate information as requested by the doctor and that this information may include photographs or videos taken by me with a mobile device.
•I understand that telehealth carries technology risks and that there may be an interruption in service or lack of audio/visual quality.
•I understand that the telehealth consultation may be recorded for clinical documentation and quality assurance purposes.
•I understand that based on the telehealth consultation, follow up treatment may be indicated.

Patient Acknowledgement – Patient Privacy, HIPAA, and Administrative Matters
•I understand that all electronic medical communications carry some level of privacy risk for the security of my health information and I understand that my doctor and my doctors staff will use good faith efforts to protect the privacy of my health information and to minimize these risks.
•I understand that during the COVID-19 national public health emergency the federal government announced that it will not enforce HIPAA regulations (regarding the privacy of health records) in connection with medical and dental offices’ good faith provision of medical or dental services using nonpublic facing audio or video remote communications services.

PATIENT ACKNOWLEDGEMENT –TELEHEALTH CONSULTATION SERVICES
•I agree to follow any technology instructions provided by the doctor for the telehealth consultation including the use of applications that allow video chats such as Zoom, FaceTime, Facebook Messenger video chat, Google Hangouts, or Skype.
•I acknowledge that the telehealth consultation may involve requests for photos or videos taken with my mobile device and transmitted to the dental office through unencrypted applications.
•I understand that I am responsible for any payment resulting from this consultation that is not covered by a dental insurance plan.
•My typed name below acknowledges I that have read and understand this document, that I understand the information provided to me by the doctor and/orstaff, and that my questions have been answered to my satisfaction.