{"id":816,"date":"2025-11-18T16:58:18","date_gmt":"2025-11-18T16:58:18","guid":{"rendered":"https:\/\/stephanie.openteledentistry.com\/?page_id=816"},"modified":"2025-11-18T16:59:31","modified_gmt":"2025-11-18T16:59:31","slug":"teledentistry-consent-form","status":"publish","type":"page","link":"https:\/\/stephanie.openteledentistry.com\/?page_id=816","title":{"rendered":"Teledentistry Consent Form"},"content":{"rendered":"\t\t
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\n\t\t\t\t\t\r\n\r\n\r\n \r\n \r\n Teledentistry Consent Form - Your Smile Partners PLLC<\/title>\r\n\r\n <!-- Google Fonts -->\r\n <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@400;500;700&display=swap\" rel=\"stylesheet\">\r\n\r\n <style>\r\n body {\r\n font-family: 'Roboto', sans-serif;\r\n background: #f9fafb;\r\n margin: 0;\r\n padding: 0;\r\n color: #222;\r\n }\r\n\r\n .container {\r\n max-width: 900px;\r\n margin: 2rem auto;\r\n background: #ffffff;\r\n border-radius: 16px;\r\n padding: 2.5rem;\r\n box-shadow: 0 4px 20px rgba(0,0,0,0.08);\r\n }\r\n\r\n h1, h2, h3 {\r\n font-weight: 700;\r\n color: #2a4365;\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n font-size: 1.8rem;\r\n margin-bottom: 0.5rem;\r\n }\r\n\r\n h2 {\r\n margin-top: 2rem;\r\n font-size: 1.2rem;\r\n }\r\n\r\n p, label {\r\n font-size: 1rem;\r\n line-height: 1.5;\r\n margin-bottom: 0.8rem;\r\n }\r\n\r\n .info {\r\n text-align: center;\r\n margin-bottom: 2rem;\r\n font-size: 0.95rem;\r\n color: #555;\r\n }\r\n\r\n input[type=\"text\"], input[type=\"date\"], input[type=\"email\"], textarea {\r\n width: 100%;\r\n padding: 0.6rem;\r\n margin-top: 0.3rem;\r\n margin-bottom: 1rem;\r\n border: 1px solid #ddd;\r\n border-radius: 8px;\r\n background: #f1f5f9;\r\n font-size: 1rem;\r\n }\r\n\r\n .signature-line {\r\n display: flex;\r\n gap: 2rem;\r\n flex-wrap: wrap;\r\n margin-top: 1rem;\r\n }\r\n\r\n .signature-line input {\r\n flex: 1;\r\n }\r\n\r\n button {\r\n background: #2b6cb0;\r\n color: white;\r\n border: none;\r\n border-radius: 8px;\r\n padding: 0.8rem 1.5rem;\r\n font-size: 1rem;\r\n cursor: pointer;\r\n transition: 0.3s;\r\n margin-right: 1rem;\r\n }\r\n\r\n button:hover {\r\n background: #2c5282;\r\n }\r\n\r\n .actions {\r\n text-align: center;\r\n margin-top: 2rem;\r\n }\r\n\r\n .footer-note {\r\n margin-top: 2rem;\r\n font-size: 0.9rem;\r\n text-align: center;\r\n color: #666;\r\n }\r\n\r\n <\/style>\r\n<\/head>\r\n<body>\r\n\r\n <div class=\"container\">\r\n <h1>Teledentistry Consent Form<\/h1>\r\n <div class=\"info\">\r\n <p><strong>Your Smile Partners PLLC<\/strong><br>\r\n 99 Wall St, New York, NY 10005<br>\r\n Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/p>\r\n <\/div>\r\n\r\n <form id=\"consentForm\">\r\n\r\n <h2>1. Patient Information<\/h2>\r\n <label>Full Name:<br><input type=\"text\" name=\"fullName\" required><\/label>\r\n <label>Date of Birth:<br><input type=\"date\" name=\"dob\" required><\/label>\r\n <label>Address:<br><input type=\"text\" name=\"address\" required><\/label>\r\n <label>Phone:<br><input type=\"text\" name=\"phone\" required><\/label>\r\n <label>Email:<br><input type=\"email\" name=\"email\" required><\/label>\r\n\r\n <h2>2. Purpose of Teledentistry<\/h2>\r\n <p>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.<\/p>\r\n\r\n <h2>3. Nature of Services<\/h2>\r\n <p>I acknowledge that teledentistry consultations may include:<\/p>\r\n <ul>\r\n <li>Real-time video visits<\/li>\r\n <li>Secure transmission of photographs, radiographs, and reports<\/li>\r\n <li>Review of remote monitoring data or mobile app information<\/li>\r\n <\/ul>\r\n <p>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.<\/p>\r\n\r\n <h2>4. Benefits and Risks<\/h2>\r\n <p><strong>Benefits:<\/strong> Improved access, reduced travel, convenience, and scheduling flexibility.<\/p>\r\n <p><strong>Risks:<\/strong> Delays due to technical issues, incomplete clinical information compared to in-office exams, and potential unauthorized access despite encryption safeguards.<\/p>\r\n\r\n <h2>5. Privacy and Security<\/h2>\r\n <p>Your Smile Partners PLLC uses HIPAA-compliant platforms and encryption protocols to protect my information. I understand no system is 100% secure.<\/p>\r\n\r\n <h2>6. Patient Responsibilities<\/h2>\r\n <p>I agree to provide accurate medical history, ensure a private setting for sessions, test my equipment, and promptly report technical issues.<\/p>\r\n\r\n <h2>7. Financial Responsibility<\/h2>\r\n <p>I understand insurance may cover teledentistry but that I am responsible for applicable co-payments, deductibles, and uncovered charges.<\/p>\r\n\r\n <h2>8. Consent to Treatment<\/h2>\r\n <p>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.<\/p>\r\n\r\n <h2>9. Acknowledgment and Signature<\/h2>\r\n <div class=\"signature-line\">\r\n <label>Patient Signature:<br><input type=\"text\" name=\"patientSignature\" required><\/label>\r\n <label>Date:<br><input type=\"date\" name=\"signatureDate\" required><\/label>\r\n <\/div>\r\n\r\n <h3>If the patient is a minor or unable to sign:<\/h3>\r\n <label>Authorized Representative Name:<br><input type=\"text\" name=\"repName\"><\/label>\r\n <label>Relationship to Patient:<br><input type=\"text\" name=\"repRelation\"><\/label>\r\n <label>Signature:<br><input type=\"text\" name=\"repSignature\"><\/label>\r\n <label>Date:<br><input type=\"date\" name=\"repDate\"><\/label>\r\n\r\n <div class=\"actions\">\r\n <button type=\"button\" onclick=\"printForm()\">\ud83d\udda8 Print<\/button>\r\n <button type=\"submit\">\ud83d\udce4 Submit & Upload<\/button>\r\n <\/div>\r\n <\/form>\r\n\r\n <div class=\"footer-note\">\r\n <p>Thank you for choosing Your Smile Partners PLLC for your teledentistry needs. If you have questions, contact us at <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a>.<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n <script>\r\n \/\/ Trigger Print\r\n function printForm() {\r\n window.print();\r\n }\r\n\r\n \/\/ Form Submission Handling (redirect to Dropbox upload request)\r\n document.getElementById('consentForm').addEventListener('submit', function(e) {\r\n e.preventDefault();\r\n alert(\"Form saved! You will now be redirected to upload your signed PDF copy.\");\r\n window.location.href = \"https:\/\/www.dropbox.com\/request\/gdRmWuwrMys3cW8R8Xua\";\r\n });\r\n <\/script>\r\n\r\n<\/body>\r\n<\/html>\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>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 Full Name: Date of Birth: Address: Phone: Email: 2. Purpose of Teledentistry I understand that teledentistry involves the use of secure electronic communications to allow dental providers at…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=816\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"content-type":"","footnotes":""},"class_list":["post-816","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/816","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=816"}],"version-history":[{"count":4,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/816\/revisions"}],"predecessor-version":[{"id":820,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/816\/revisions\/820"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=816"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}