Telehealth Consent Form

Patient Information

Patient Name

Date

Consent to Participate in Telehealth Services

Purpose and Nature of Telehealth Services. Telehealth uses secure audio, video, and digital communications to support evaluation, consultation, diagnosis, treatment planning, follow-up, education, and monitoring related to orofacial pain, TMJ, and oral medicine conditions.
Care Team Participation. Services may involve licensed professionals engaged by Dr. Khalifeh as needed for your care.
Participation of Others. With your permission, family, caregivers, or legal representatives may join visits as appropriate.
Information Shared. Medical/dental records, images (including intraoral photos and radiographs), audio/video, text communications, symptoms, pain levels, and treatment response may be exchanged.
Privacy and Confidentiality. Telehealth communications are safeguarded under applicable privacy laws. Your identifiable information is disclosed only for treatment, payment, healthcare operations, or as required by law.
Security and Technical Support. Reasonable safeguards are used to protect data; however, electronic communications have inherent risks (e.g., connectivity issues). Non-clinical technical staff may assist and are bound by confidentiality.
Risks, Benefits, and Limitations. Benefits include improved access and reduced travel; limitations include reduced physical examination. Some conditions require in-person evaluation. For emergencies, call 911.
Medical Records and Accuracy. Telehealth documentation becomes part of your medical record. Provide accurate, complete information and notify us of changes.
Right to Withdraw. Your consent is voluntary. You may withhold or withdraw consent at any time before or during a session without affecting future care options.
Billing and Insurance. Coverage and copayments vary by plan and jurisdiction.
Patient Responsibilities. Use a private setting, adequate lighting, a working camera/microphone, and a stable internet connection; follow pre-visit instructions.

I am the patient or legally authorized representative and at least 18 years old (or otherwise permitted to consent). I have read and understand the information above, had my questions answered, and I voluntarily consent to receive telehealth services from Mohammad Khalifeh, DDS, MS. I understand this consent will be stored in my medical record.

Signature (sign in the box)

Printed Name

Date Signed

After you finalize, you can print/save or submit. Submitting emails a PDF copy and saves a copy on the server.