Consent to Participate in a Teledentistry System
Purpose: The purpose of this form is to permit the use of a system of dental care called “teledentistry.”
The dental care providers in this system include: Dental Professional - Name: Erin Lawrence, RDH, Michelle Schmidt, RDH and Todd Higginbotham, DDS.
Dental care is provided at the direction of the following dentist:
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.
1. What is a teledentistry consultation? Teledentistry is a way to provide care for people who do not or cannot go to a dentist’s office. 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.
2. What happens during teledentistry consultation? The RDH will 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.
3. What are the risks, benefits and alternatives? The benefits of teledentistry include having access to a dentist and additional dental information without having to travel to a dental office or clinic. 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. Recommendations will be made to you about your future dental care after the teledentistry consultation. These 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 become known. The alternative to teledentistry consultation is a face-to-face visit with a dentist.
4. Confidentiality. Current federal and Arkansas laws regarding confidentiality apply to the information used or disclosed during your teledentistry consultation.
5. Rights. You may choose not to participate in a teledentistry consultation at any time. If you decide not to participate, it will not affect your right to future care or treatment. You have the option to seek dental consultation or treatment in a dental office at any time.
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 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.