• TELEMEDICINE CONSENT FORM

  • PURPOSE: The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine care.

    RECORDS: Telecommunications with patients will not be recorded and stored. The dentist will store and will view your health information (ex: x-rays, photographs, digital impressions etc) to evaluate your condition at a later time.  

    TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

    ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

    PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.

  • By signing this form,

    I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

    I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

    I understand that I can be charged the additional fees that my insurance does not cover.

    I accept that I authorize the use of telemedicine for my treatment and diagnosis.

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