Simply Virtual Consult Informed Consent Form
The virtual consultation involves the use of electronic communications to enable your orthodontist to make an assessment from a different location. The information gained from the virtual consult may include health information, medical images, two-way audio and video output files.
Electronic systems will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Possible risks with Virtual Consultations
There are possible risks associated with the use of virtual consultations. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decisions by your orthodontist.
- Delays in diagnosis and treatment could occur due to deficiencies or failures of the equipment.
- In very rare instances, security protocols could fail, causing a breach of privacy or personal information.
- The virtual consultation is not intended to be a substitute for a general dental evaluation. It is recommended that a clinical examination be undertaken by your dentist prior to the commencement of orthodontic treatment to detect for any dental decay, gum disease or oral pathology.
If the video visit does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second video visit.
I can change my mind and stop the virtual consultation at any time, including in the middle of a virtual visit.
I am aware that screenshots or photographs may be taken throughout the virtual consultation to use as part of standard diagnosis.
To enable us to continue to treat you with the highest standard of care, please answer the following questions as accurately as possible.