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Teledentistry Consent Form - Your Smile Partners PLLC

Teledentistry Consent Form

Your Smile Partners PLLC
99 Wall St, New York, NY 10005
Email: talk@yoursmilepartners.com

1. Patient Information

2. Purpose of Teledentistry

I understand that teledentistry involves the use of secure electronic communications to allow dental providers at different locations to share my health information for diagnosis, consultation, treatment, education, and ongoing care.

3. Nature of Services

I acknowledge that teledentistry consultations may include:

  • Real-time video visits
  • Secure transmission of photographs, radiographs, and reports
  • Review of remote monitoring data or mobile app information

I understand that in-office evaluation may be required if my condition cannot be adequately assessed remotely, and that emergency conditions require immediate in-person care.

4. Benefits and Risks

Benefits: Improved access, reduced travel, convenience, and scheduling flexibility.

Risks: Delays due to technical issues, incomplete clinical information compared to in-office exams, and potential unauthorized access despite encryption safeguards.

5. Privacy and Security

Your Smile Partners PLLC uses HIPAA-compliant platforms and encryption protocols to protect my information. I understand no system is 100% secure.

6. Patient Responsibilities

I agree to provide accurate medical history, ensure a private setting for sessions, test my equipment, and promptly report technical issues.

7. Financial Responsibility

I understand insurance may cover teledentistry but that I am responsible for applicable co-payments, deductibles, and uncovered charges.

8. Consent to Treatment

I voluntarily consent to receive teledentistry services from Your Smile Partners PLLC and understand I may withdraw consent at any time by notifying the practice.

9. Acknowledgment and Signature

If the patient is a minor or unable to sign:

Thank you for choosing Your Smile Partners PLLC for your teledentistry needs. If you have questions, contact us at talk@yoursmilepartners.com.

Revised Instructions – HIPAA Secure Form
HIPAA Secure Process

Revised Instructions for Filling the HIPAA Secure Form

Follow these quick, secure steps. We’ve used light background highlights to keep each instruction easy to read.

  1. Fill out the form completely

    Enter all required details carefully. Double-check names, dates, and contact information before proceeding.

  2. Click “Print the form.”

    This creates a paper or PDF copy for your records. Most browsers allow “Save as PDF” in the print dialog.

  3. Click “Submit and Upload the form.”

    The page will guide you to the secure upload portal after submission.

  4. Finally, click “Upload the form.”

    Select the saved file from your device and press Submit. That’s it — simple steps to complete the process!

Upload the form

Tip: If the form is on this same page and labeled #consentForm, “Go to Form” will jump there. Otherwise, it will let you know.

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