Consent for Teledentistry
Tele dental/Tele health involves the use of electronic communications to enable dental care providers at different locations to share individual patient medical information for the purpose of improving patient care.
The information may be used for diagnosis, therapy, follow-up and/or education. Tele dentistry/Tele health requires transmission, via Internet or tele-communication device, of health information, which may include:
• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data
Individuals other than consulting providers may also be present and have access to my information for the tele dental/tele health session Tele dental/tele health sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting dentist(s), participant, patient or care team. I hereby release and hold harmless the dental professional(s) and Chipper Consumer Private Limited team from any loss of data or information due to technical failures associated with the tele health/telemedicine service. I understand and agree that the health information I provide at the time of my tele dental/tele health service may be the only source of health information used by the dental professionals during the course of my evaluation and treatment at the time of tele dentistry/tele health visit, and that such professionals may not have access to my full medical record or information.
I understand that it is my responsibility to provide correct medical and allergy history. In case I do not provide it,I understand that there can be untoward consequences for which I will not hold either the dental professional(s) or Chipper Consumer Private Limited responsible for it.
I understand that dentistry is not an exact science and exact results cannot be promised.I understand that the results differ based on individual structure of teeth and composition of oral tissue and will hold neither the dental professional(s) or Chipper Consumer Private Limited responsible for it
I understand that I will be given information about product(s), treatments(s) and procedures(s), as applicable, including the benefits and risks involved.
I fully understand that the consultation using tele dental/tele health is for health educational and counselling purposes pertaining to products of Chipper Consumer Private Limited.I will not hold Chipper Consumer Private Limited responsible or the hired dental professionals incase of any emergency dental treatment required.I completely understand the limitations of tele dental/tele health services and will consult a registered dental practitioner available for physical consultation which may not be from Chipper Consumer Private Limited.
All my questions have been answered to my satisfaction. I hereby consent to the use of tele dental/tele health in the provision of care and the above terms and conditions. By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorised to consent. I have carefully read and understood the above statements.