INFORMED CONSENT FOR GENERAL DENTISTRY

WORK TO BE DONE
I understand that I am having one or more of the following work done in the office of SF Transit Center

DRUGS AND MEDICATION
I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock.

CHANGES IN TREATMENT PLAN
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example: root canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions as necessary, and understand that I will be notified of changes prior to dentist performing the necessary changes.

I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized.

I hereby authorize any of the doctors or dental auxiliaries to proceed with and perform the dental restorations and treatments as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of the dental fees. I agree to pay any attorney's fees, or court costs, that may be incurred to satisfy this obligation.

Patient Signature:

Date:

Consent to Participate in Tele-Dentistry System

The purpose of this form is to get your permission for you to participate in a system of dental care called "teledentistry." You will be offered a virtual exam and limited dental treatment. You will be seen by one of our board-certified dentists.

1. What is a teledentistry consultation? Teledentistry is a way to provide care for people who do not or cannot go to a dentist's office. Teledentistry uses electronic dental records such as electronic versions of X-rays, photographs, recordings of the condition of your teeth, health and other history information. Our dentist will review your existing records. The goal of the teledentistry system is to have the dentist create recommendations for you for dental care.
2. What happens during teledentistry consultation? You will fill out an update of your medical history, explain your concerns, take pictures or videos that are sent to the dentist beforehand for review. Our dentist will review this as well as your previous pictures, radiographs and dental history and meet with you virtually for a live consultation. Please note that your medical and dental history and personal health information may be discussed with other health professionals. These discussions will occur through phone calls or "store and forward" technology. A teledentistry consultation may require more than one visit.
3. What are the risks, benefits and alternatives? The benefits of teledentistry include having access to a dentist and additional dental information without having to travel to a dental office or clinic. A potential risk of teledentistry is that a face-to-face consultation with a dentist may still be necessary after the teledentistry appointment. This could be because of your specific medical or dental condition or for other reasons. Recommendations will be made to you about your future dental care after the teledentistry consultation. These could include recommendations about whether or not to see a dentist in a dental office or dental clinic. A visit to a dental office may be needed in the future even if it is not recommended now. The recommendations may change if more information about your dental needs becomes known. The alternative to eledentistry consultation is a face-to-face visit with a dentist.
4. Confidentiality. Current federal and state laws about confidentiality apply to the information used or disclosed during your teledentistry consultation. You will be provided with a separate document, which describes how your private information will be handled. This is known as the "Notice of Privacy Practices."
5. Rights. You may choose not to participate in a teledentistry consultation at any time before and/or during the consultation. If you decide not to participate, it will not affect your right to future care or treatment. You have the option to seek dental consultation or treatment in a dental office at any time before or after the teledentistry consultation.

I have read and understand the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I agree to have records, including electronic versions of X-rays, photographs, charting of conditions and health and other history information, collected from me and shared and used in this study as described in this consent form and in the "Notice of Privacy Practices" I have received. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have requested and authorized.

Patient Signature:

Date: