Orthodontic Screening Kit: Smile! Snap! Send! Personal Details

Personal Details

First Name

Last Name

Date of Birth

Parent or Guardian Name (if under 18)

Parental supervision is required if under 13

Phone

Which one applies to you?

I am a new patient

I am a current patient

I am agreeing to conduct this transaction by electronic means and that by checking this box I am providing my electronic signature in approval with the terms of this agreement. I understand that I am sending health information to an orthodontist through Ortho Screening and I consent to receiving my results at the contact information entered and accept the terms and conditions.

ORTHOSCREENING USER TERMS OF SERVICE

1. Your Acceptance

By accessing, using or visiting the Orthoscreening website or any Orthoscreening data feeds and services provided to you on, from, or through the Orthoscreening website (collectively the "Service") you signify your agreement to these terms and conditions (the "Terms of Service"). If you do not agree to the Terms of Service, please do not use the Service. Although we may attempt to notify you when major changes are made to these Terms of Service, you should periodically review the most up-to-date version on the Orthoscreening website. Orthoscreening may, in its sole discretion, modify or revise these Terms of Service at any time, and you agree to be bound by such modifications or revisions. Nothing in these Terms of Service shall be deemed to confer any third-party rights or benefits.

2. Service

The Terms of Service apply to your use of the Orthoscreening Service, which includes all features, applications, content and downloads offered by Orthoscreening. “Content” includes the text, software, scripts, graphics, photos, sounds, music, videos, audiovisual combinations, interactive features and other materials you may view on or access through the Service. The Service includes all aspects of Orthoscreening, including but not limited to all products, software and services offered via the Orthoscreening website.ORTHODONTIC SUPPLEMENTAL INFORMED CONSENT

Delivery of Orthodontic Services by Teledentistry

You have elected to receive orthodontic services via Teledentistry which involves using electronic and digital communications between you as a patient or parent and your orthodontist. In providing Teledentistry services, your orthodontist will follow the rules and regulations of the state dental board(s) in which the doctor is licensed.

THERE ARE RISKS AND LIMITATIONS WITH TELEDENTISTRV FOR ANY DENTAL TREATMENT INCLUDING ORTHODONTICS:

• Unfortunately, some of the conditions that lead to adverse outcomes in orthodontics are difficult, if not impossible, to diagnose and treat without an in-person examination and if not diagnosed can lead to long term problems. These conditions include, but are not limited to, periodontal disease (disease of the gums and bone), root resorption (shortening of the roots of the teeth) and oral pathology (lesions that may be harmful), all of which require radiographs and/or other imaging techniques to identify. These potential complications and others are discussed in more detail in our Comprehensive Informed Consent document which we will ask you to review.

• The photography or digital imaging you provide to us can only give a superficial view and may be inadequate to identify all areas of concern. Although we strive to provide excellent service using Teledentistry, treatment or recommendations based solely on Teledentistry may not allow adequate monitoring of oral conditions, treatment progress or unexpected responses to treatment.

• When using electronic and digital communication in the provision of care, there is potential for the breach of confidentiality and/or inadvertent access of protected health information by someone other than your orthodontist, as well as a risk that a loss of electronic communication could mean the loss of Teledentistry services.

• In-person office visits are preferred for the best orthodontic outcomes. Teledentistry involves risks that an office visit might avoid, and Teledentistry is best used when an office visit is impractical or in between regular office visits. Your orthodontist will use his/her best judgment in determining when Teledentistry is appropriate.

By clicking I agree I am acknowledging that I understand the risks and limitations of teledentistry and hereby consent to forwarding patient-identifiable information to your orthodontist using electronic communications and consent to treatment using Teledentistry.