Introduction
Cypress Dental offers telephone and video assisted consultations (i.e. Zoom) to our patients who are not able to visit our office in person, or when a provider is unavailable for an in-person appointment.

Before we use video assisted services, you need to understand what is involved when using these methods and give your consent.

Your privacy is very important. To this end:

• The device (i.e. computer) we use for virtual consultations is password protected.
• Cypress dental abides by the Health Insurance Portability and Accountability Act (HIPAA)
• A written summary of the visit is documented in your dental chart, just as it would be if you came into the office.

Potential Risks include, but may not be limited to:

• While video usually provides a good visual image, since you are not sitting face-to-face with your dental provider, we will not be able to provide definitive diagnosis. This consultation is for informational purposes. Any recommendations are not conclusive and an in-office examination may be advised if x-rays and further testing are needed,
• The security of video on the internet can not be absolutely guaranteed. Cypress Dental uses applications that offer significant security to online meetings. We can not independently assess the adequacy of these online programs, but we continuously monitor professional recommendations about the services we use.
• Equipment failures and technical challenges may delay consultations at times. We do our best to ensure that meetings go smoothly.
• If your consultation is interrupted due to equipment failure, we will do our best to continue our visit by telephone.

I UNDERSTAND that:

• My privacy is important and protected as described in this document.
• There are some potential risks to telephone and video consultations. Cypress Dental cannot guarantee the security of the information I share over the internet.
• I have the right to withdraw my consent at any time. I understand that my withdrawal of consent will not affect my future care or treatment.
• Cypress Dental or my dental provider may withdraw the option of using telephone or video consultation at any time.

I have read and understand the information provided above regarding telephone and video consultations. I hereby give my informed consent for my dental provider at Cypress Dental to use telephone and/or video consultation.