Telehealth Consent Form

I, the patient or guardian, hereby consent to engage in telehealth with Dr. Robert Pham at Pinnacle Orthodontics, Inc. I understand that telehealth includes consultation, treatment, and transfer of health information using interactive audio, video, or data communications. I understand that telehealth also involves the communication of my medical/dental/orthodontic health information, both orally and visually.

I understand that I have the following rights with respect to telehealth:

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
The laws that protect the confidentiality of medical information also apply to telehealth. As such, I understand that the information disclosed during the course of a telehealth appointment is confidential.
Although there are many benefits to telehealth, including convenience, there are also potential risks. Potential risks include, but are not limited to, the possibility, despite reasonable efforts on the part of Pinnacle Orthodontics, Inc. that the transmission of information could be disrupted or distorted by technical failures or the transmission of information could be interrupted by unauthorized persons. Pinnacle Orthodontics, Inc. does not record the telehealth session. Despite these efforts, it is still possible an unauthorized person could gain access, interrupt, or record a telehealth session. Pinnacle Orthodontics, Inc. is not responsible for any security risks which may occur due to internet disruptions or technical failures.
In Addition, I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if Dr. Pham believes I would be better served by a face-to-face appointment, I will be referred and scheduled for future appointments in that manner
I accept that telehealth does not provide emergency services
I understand that I am responsible for (1) providing the necessary computer, tablet, or phone and internet access for the telehealth sessions. (2) the information security on my computer or device (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for the telehealth session, and (4) signing up for and downloading software that will be used, if needed.

I have read, understand, and agree to the information provided above.

I understand that by typing my name I am electronically signing this document.

Name / Signature:

Date:

Your information will be encrypted.