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.