PURPOSE: The purpose of this form is to get your permission for you to participate in a system of dental care called ‘teledentistry’. Teledentistry allows a dentist to view your records through the internet. The Endodontist will then make recommendations about your treatment. The Endodontist may not see you in person.

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 may use electronic dental records such as electronic versions of X-rays, photographs, recordings of the condition of your teeth, health and other history information. These records or other electronic communications are known as “store and forward” records. The goal of teledentistry is to have the dentist create recommendations for you for dental care.

2. 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 teledentistry consultation is a face-to-face visit with a dentist.

The practice of dentistry is not an exact science. Therefore, any specific results cannot be guaranteed.

3. CONFIDENTIALITY. Current federal and provincial laws about confidentiality apply to the information used or disclosed during your teledentistry consultation.

4. 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.

My dental care provider has discussed with me 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.