Teledentistry Consent

Use the form below to submit your Teledentistry Consent.

Teledentistry COnsent

Use the form below to submit your Teledentistry Consent..

  • Teledentistry Consent

    I am acknowledging that I wish to receive a teledentistry consultation with my dentist. In the absence of radiographs, I understand that I may be asked to send photographs or other documentation as requested by the dentist. I will try to provide as much detailed information as I can. I understand that the doctor is limited to what they are able to determine in these circumstances. I also understand that if I am experiencing pain or swelling that is life threatening, I will call 911 or go to an emergency room. I understand that I am responsible for any payment resulting from this consultation that is not covered by a dental insurance plan. In addition, I understand and consent to this consultation being recorded for clinical documentation and accuracy.
  • Sign Below

    By signing below, I agree to the teledentistry terms.
  • This field is for validation purposes and should be left unchanged.