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Telehealth Consent

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

  1. All dental care and treatment I receive from Providers will be initially be provided using telehealth and my Providers may not be able to provide any dental care and treatment to me without the use of telehealth. In such case a referral may be required.
  2. I understand I have the right to withhold or withdraw consent to the use of telehealth at any time by terminating my use of the CVSTOM Co. service
  3. I understand the laws that protect the confidentiality of my medical information also apply to telehealth and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
  4. I understand that a variety of alternative methods of orthodontic care may be available to me, and that I may choose one or more of these at any time.
  5. I understand that I have a right to access my medical information and copies of medical records in accordance with California law.

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

  1. I understand there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my dental professional that: the transmission of my dental or medical information could be disrupted or distorted by technical failures; the transmission of my dental or medical information could be interrupted by unauthorized persons; and/or the electronic storage of my dental or medical information could be accessed by unauthorized persons.
  2. I understand that telehealth may involve electronic communication of my personal medical information to health care providers who may be located in other areas, including out of state.
  3. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

“Telehealth” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications, including the use of telephone, cellular phone, Internet, email, text, IM, and programs such as Skype and Face Time. I understand that telehealth also involves the communication of my dental and medical information, both orally and visually, to dental care providers (“Providers”) located in California.

By signing up to this service: (i) I certify to have read and understand the information provided above and all of my questions have been answered to my satisfaction by my health care practitioner, (ii) I hereby give my informed consent for the use of telehealth by CVSTOM Co. in my orthodontic diagnosis. *