Consents and Policies
Below, are copies of the consents and policies that you will be asked to sign electronically. Please review the information carefully and keep this information for your records.
I acknowledge that I was provided with a copy of the Guide to Patient’s Services.
I have read, understand, and agree to abide by the aforementioned appointment policy and payment policy. I acknowledge that I was provided with a copy of the Touro Dental Health Notice of Privacy Practices. I acknowledge that I reviewed and understand the consent to dental treatment You will be asked to provide an electronic signature in acknowledgment of the above.
Patients Who Are Minors
A parent or legal guardian must accompany patients who are minors at every visit. This accompanying adult is responsible for payment of the account or must provide complete and accurate information about the guarantor on the insurance that will be billed.
We take great pride in the quality of care that we deliver. In an effort to maintain this high -level of care, we have instituted appointment guidelines regarding cancellation /no-show/lateness. Compliance with this policy will allow patients to receive treatment in a timely and efficient manner, promoting optimal care and oral health.
- Once appointments are scheduled, patients are expected to attend each and every session at the appointed time.
- If you are going to be more than 15 minutes late for your scheduled appointment, please call to let us know so that we may notify your doctor.
- All cancellations must be communicated to the department 48 hours in advance or 72 hours in advance of a surgical and/or sedation procedure.
- If you cancel without proper notice or fail to show for 3 consecutive visits, you may be discharged from being provided care at the college.
- The College reserves the right not to reschedule patients who have been discharged for failing to show for prior scheduled appointments.
Touro Dental Health reserves the right to discontinue dental treatment at its sole discretion. Should treatment be terminated, any remaining credit balance for services not yet provided will be refunded. If you have a complaint that cannot be resolved at the student or faculty level, please contact the Director of Clinical Operations 914-594-2707.
We appreciate your understanding and cooperation with this policy.
I have read, understand and agree to abide by the aforementioned policy.
Some insurance companies, pharmacies, or other entities send information on current and past patient prescriptions to electronic databases. Touro Dental Health’s electronic record system may, from time to time, query available prescription databases and receive such information concerning your past prescriptions. These queries may not identify all your current and past prescriptions. Therefore, it is important for you to keep an up-to-date list and to provide this information to your provider. By signing the consent, you give Touro Dental Health Permission to access these electronic data bases.
Authorization for Release of Information
I hereby authorize and consent Touro College of Dental Medicine to release to government agencies, insurance carriers, or others who are financially liable for the dental care, all information needed to substantiate payment for such care, and permits others who are representatives thereof to examine and make copies of all records relating to such care and treatment. However, after disclosure has been made, it cannot be revoked retroactively to cover information released prior to revocation.
Photo and Video
Touro Dental Health will take or use existing photographs, audio and /or video recordings, x-rays, film, movies, or other images or recordings of patients for education and training, student portfolios, students research and presentations, etc.
Assignment of Benefits
I hereby assign and set over to the above named Touro College of Dental Medicine, Inc. sufficient monies and/or benefits to which I may be entitled from government agency insurance carrier or others who are financially liable for my dental, medical care to cover the costs of the care and treatment rendered to myself or my dependent in said practice. I understand that I am responsible for charges not covered by my insurance plan.
Email/Text Message Communications
As a patient, you agree that we may communicate with you by electronic means such as (but not limited to) email or text message. We will make every attempt to communicate over the Internet using a secure (encrypted) email/text messaging system. However, you must assume that there is no assurance of confidentiality when communicating via email /text messages. Touro Dental Health will not communicate health information that is specially protected under state and federal law (e.g., HIV/AIDS, substance abuse, mental health information) via email/texts.
Please Read This Information Carefully
Email communications are a two-way communication. However, responses and replies to emails sent to or received by either you or your health care provider may be hours or days apart. This means that there could be a delay in receiving treatment for an acute condition.
Email messages on your computer, laptop, or other device have inherent privacy risks especially when your email access is provided through your employer or when access to your email messages is not password protected.
Email is sent at the touch of a button. Once sent, an email message cannot be recalled or cancelled. Errors in transmission, regardless of the sender’s caution, can occur. You can also help minimize this risk by using only the email address that you provide to our practice/ program/ provider.
In order to forward or to process and respond to your email, individuals at Touro Dental Health other than your health care provider may read your email message. Your email message is not a private communication between you and your treating provider. Neither you nor the person reading your email can see the facial expressions or gestures or hear the voice of the sender. Email can be misinterpreted.
At your health care provider’s discretion, your email message and any and all responses to them may become part of your medical record.
I understand and agree to the following:
- I certify the email address provided on this request is accurate, and that I accept full responsibility for messages sent to or from this address.
- I have received a copy of the IMPORTANT INFORMATION ABOUT PATIENT EMAIL form, and I have read and understand it.
- I understand and acknowledge that communications over the Internet and/or using the email system may not be encrypted and may not be secure; that there is no assurance of confidentiality of information when communicated via email.
- I understand that all email communications may be forwarded to other providers for purposes of providing treatment to me.
- I agree to hold Touro Dental Health and individuals associated with it harmless from any and all claims and liabilities arising from or related to this request to communicate via email.
If you have an urgent or an emergency, you should not rely solely on provider / patient email to request assistance or to describe the urgent or emergency. Instead, you should act as though provider / patient email is not available to you and seek medical attention.
I understand this consent will remain in force until I revoke it in writing.
By electronically signing these consents, listed above, I hereby state that I have read and understand these consent forms, and that I have been given the opportunity to ask questions, I might have, and that all my questions have been answered in a satisfactory manner.