The alternative to teledentistry consultation is a face-to-face visit with a dentist. I may choose not to participate in a teledentistry consultation at any time before and/or during the consultation. If I decide not to participate, it will not affect my right to future care or treatment. I have the option to seek dental consultation or treatment in a dental office at any time before or after the teledentistry consultation.
Diane Bonanni, DMD has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all 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 and shared and used as described in this consent form I have received. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have requested