Consent to Care for a Teledentistry Visit

To assist you in understanding the services provided by Dentistry.One, please take a moment to read the terms of service before using offered services. The purpose of this form is to obtain your consent for a teledentistry visit with a dental provider at Dentistry One LLC and affiliated P.C. using Dentistry.One, a virtual first oral health platform.  

What is teledentistry?

Teledentistry is a way to visit with oral healthcare providers, such as dentists. You can talk to a dentist from any place, including your home. You don’t go to a dental office. 

How do I use teledentistry?

• You talk to a dentist by smartphone, computer, or tablet. Using video so you and your provider can see each other. 
• You can also have questions answered through messaging without having a video visit.

How does teledentistry help me?

• You don’t have to visit a dental office to see a dentist.
• You won’t risk getting sick from other people. 
• You can talk to a dentist to see if you need in-person care.
• You can work with a care coordinator to get help with in-person care.
• You can learn how you can improve your oral health.

Can teledentistry be bad for me? 

• You and the dentist won’t be in the same room, so it may feel different than an office visit.
• The dentist won’t be able to take X-rays during a teledentistry visit, and they may be unable to diagnose every issue. (We don’t know if this is more common with teledentistry visits.)
• The dentist may decide you still need an office visit.
• Technical problems may interrupt or stop your visit before you are done.

Will my teledentistry visit be private?

• We will not record visits with the dentist, though, during the visit, your provider may conduct a remote oral examination during which video, audio, and/or photo recordings may be taken and become part of your health record. 
• If people are close to you, they may hear something you did not want them to know. You should be in a private place so other people cannot hear you.  
•  The dentist will tell you if someone can hear or see you.
• Dentistry.One’s telehealth technology is designed to protect your privacy.
•  Using the Internet for teledentistry, use a private and secure network.  
• There is a very small chance that someone could use technology to hear or see your teledentistry visit. 
• To assist in coordinating care or referral from a healthcare provider, Dentistry.One may disclose PHI for such purposes.
• In connection with your teledentistry visit, details of your medical history and personal health information may be discussed and shared with other health professionals and staff.
• Our Privacy Policy which describes how your private information will be handled, can be found at https://dentistry.one/privacy-policy/.

What if I want an office visit, not a telehealth visit?

• Dentistry.One is a virtual first oral health platform. We do not have brick-and-mortar dental practices though do have care coordination services that can assist you in locating a provider in your area.

What if I try teledentistry and don’t like it?

• You can stop using teledentistry at any time, even during a teledentistry visit.
• You can still get an office visit if you no longer want a teledentistry visit.  Our Care Coordination team would be happy to assist you.

How much does a telehealth visit cost? 

• If you have insurance, what you pay depends on your insurance.
• A teledentistry visit will not cost any more than an office visit.
• If the dentist decides you need an office visit in addition to your telehealth visit, you may have to pay for both.

What digital communication is used by Dentistry.One to contact me?

• As a teledentistry platform Dentistry.One will provide oral health services via mobile phone, messages, e-mail, and online communication.
• These communications comply with privacy regulations as outlined under Privacy Practices. 
• In addition, we may receive your contact information through your employer, broker, etc., that contract with Dentistry. One is to provide a teledentistry solution.
• By consenting, you agree that Dentistry.One can communicate this way and understand that safeguards are in place; the content could be intercepted by others or not be encrypted. If you decline, the use of Dentistry.One will not be available to you.

What are my rights as a patient?

• You have the right to ask questions of your provider about the risks, benefits, and alternatives to teledentistry visits and to know the provider’s licensure and qualifications. 
• You have the right to receive interactive, real-time communications with the dental provider(s) providing your teledentistry visit, both at the time and within thirty (30) days after your teledentistry visit.
• You may withhold or withdraw your consent to a teledentistry visit at any time before and/or during the visit.
• For a complete list of rights and more information regarding the privacy of your data and health information, please consult our Privacy Policy.

Do I have to sign this document?

No. Only sign this document if you want to use teledentistry.

 Do not sign this form until you start your first telehealth visit. The dentist will discuss it with you.

What does it mean if I sign this document?

If you sign this document, you agree that:

• A Dentistry.One provider or employee talked about the information in this document.
• A Dentistry.One provider or employee answered all your questions.
• You want a teledentistry visit.

I have read and understand the Consent to Care for a Teledentistry Visit and, with this, give my consent to participate in a Teledentistry visit. If I consent on behalf of a minor patient, I now certify that I am the legal parent or guardian of the patient and am authorized to provide such consent.