As validated by my signature on the bottom of this form:
I am acknowledging that I wish to receive this TeleDentistry evaluation from Dr. Plastow.
In the absence of radiographs (x-rays), I understand that I may be asked to send photographs or other documentation as requested by the dentist. I will try to provide as much detail as I can. I understand that the doctor is limited to what he is able to determine in these circumstances.
I understand that the doctor may request follow-up to this TeleDentistry Questionaire with either a Virtual Consultation or an in-office visit so that he can further evaluate and discuss your dental treatment options. It goes without saying, that dental procedures can only be provided with in-office visits.
I also understand that if I am experiencing pain or swelling that is life threatening, I will call 911 or go to the emergency room.
I understand and consent to this consultation being recorded for clinical documentation and accuracy.
I understand that I am responsible for any payment resulting from this consultation and that payment is due at the time of service, regardless if treatment is covered under my insurance plan. I understand that Dr. Plastow's office will submit forms for payment and you will be reimbursed if provider covers your TeleDentistry visit.
Please provide credit card information below.