Introduction:

Teledentistry refers to the use of telehealth systems and methodologies in dentistry. Telehealth refers to a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery. Teledentistry can include patient care, consultation, remote examination, and education delivery using, but not limited to, the following modalities.

• Patient medical/ dental records
• Dental images/radiographs/clinical pictures and medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

Improved access to the dental practitioner by enabling a patient to remain at a remote site, while the practitioner answers questions, provides guidance and obtains test results if available remotely.
More efficient dental consultation, evaluation and management if possible.
Possible Risks:

As with any procedure, there are potential risks associated with the use of teledentistry/telemedicine. These risks include, but may not be limited to: 

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the practitioner and consultant(s)
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical/dental information
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By signing this form or by verbal consent, I understand the following:

1. I wish to engage in a teledentistry consultation with the Bala Kids Dentistry team.

2. I understand that the use of teledentistry is a way to provide care for people who cannot go the dental office. Teledentistry uses electronic dental records such as previous x-rays in an existing patient’s records, photographs or recordings of the condition of your teeth, health, and other health history information to the absolute best of the provider’s ability.

3. I understand that the laws that protect privacy and the confidentiality of medical information also apply to teledentistry, and that no information obtained in the use of teledentistry which identifies me will be disclosed to researchers or other entities without my consent.

4. Bala Kids Dentistry team member has explained to me how the audio/video conferencing technology will be used. I am aware that this type of consultation will not be the same as a direct dentist/patient visit due to the fact that I will not be in the same room as the dental practitioner. 

5. I understand that a face-to-face consultation with the dentist may still be necessary after the teledentistry appointment. This could be because of my specific dental or medical condition. Recommendations will be made about my future dental care after the teledentistry consultation.

6. I understand that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.

7. I understand that the Bala Kids dentistry team member or I can discontinue the teledentistry consult/visit if it is felt that the videoconferencing connections are not adequate for the situation

8. I understand that teledentistry may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state if deemed necessary.

9. I understand that Bala Kids Dentistry information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider. All people who may be present will maintain confidentiality of the information obtained

10. I understand that it is my duty to inform my dentist of electronic interactions regarding my care that I may have with other healthcare providers.

11. I understand that I may expect the anticipated benefits from the use of teledentistry in my care, but that no results can be guaranteed or assured.

12. I understand that there are charges based on duration of the time consultation and documentation of the teledentistry consultation. These charges may or may not be covered by my insurance company and I take responsibility to pay those charges to Bala Kids Dentistry. Therefore, the initial fee for a teledentistry consultation is $45 and payment is expected at the time of service.

13. I understand that my insurance company will be charged if applicable and acceptable by them, and I may be financially responsible for full or partial payment of any non-covered or partially covered services. I realize that it is my responsibility to contact my individual insurance carrier to ensure that teledentistry services are covered.

14. I have made the choice to participate in a teledentistry consultation. I assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.

Patient Consent To The Use of Teledentistry

I have read and understand the information provided above regarding teledentistry, have discussed it with my pediatric dentist or such assistants as may be designated, and all of my questions have been answered to my satisfaction. As the parent or legal guardian (s) of the patient named above I agree with the following statements:

• I have read or had this form read to me and understood the nature of teledentistry.
• I have given consent of my own free will (or by a parent or guardian)
• I fully understand its contents including the risks and benefits of the procedure(s)
• I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

I hereby authorize the providers of Bala Kids Dentistry to use teledentistry in the course of my child’s diagnosis and treatment. By signing this form or by verbal acceptance, I hereby give my informed consent for the use of teledentistry in my child dental care.