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TELEHEALTH CONSULTATION INFORMED CONSENT & TERMS OF SERVICE

Practice Name: Clarus Surgical Consult
Provider: Dr. Benjamin Kur, DDS, MD

1. NATURE OF SERVICES

I understand that the services provided through this platform are limited to educational guidance, second opinions, and case review related to oral and maxillofacial conditions.

These services:

  • Do not constitute comprehensive dental or medical care
  • Do not replace an in-person clinical examination
  • Are based solely on the information and records I provide

2. NO DOCTOR–PATIENT RELATIONSHIP (LIMITED SCOPE)

I acknowledge that participation in this consultation does not establish an ongoing doctor–patient relationship, except as required by law for the limited purpose of this consultation.

No prescriptions, procedures, or definitive diagnoses will be made.

3. LIMITATIONS OF TELEHEALTH

I understand that:

  • The provider cannot perform a physical examination
  • Clinical findings may be incomplete or inaccurate due to:
    • Image quality
    • Missing records
    • Lack of tactile evaluation

This may affect the accuracy of recommendations.

4. NOT FOR EMERGENCIES

I understand this service is not intended for emergencies.

If I experience:

  • Severe pain
  • Swelling
  • Bleeding
  • Difficulty breathing or swallowing

I will seek immediate care by calling 911 or visiting the nearest emergency facility.

5. PATIENT RESPONSIBILITIES

I agree to:

  • Provide accurate and complete information
  • Upload relevant imaging (e.g., panoramic X-rays, CBCT if available)
  • Follow up with an in-person provider for definitive care

6. PRIVACY & HIPAA

I understand that:

  • My information will be stored and transmitted using HIPAA-compliant systems
  • No system is completely risk-free
  • Reasonable safeguards will be used to protect my data

7. PAYMENT & REFUND POLICY

  • Payment is required prior to consultation
  • Services are non-refundable once review has begun
  • Missed virtual appointments may not be refunded

8. RECORDINGS & COMMUNICATION

I understand that:

  • Consultations may be documented for medical and legal purposes
  • I may receive written or video-based feedback

9. ACKNOWLEDGMENT

By signing below, I confirm that:

  • I have read and understand this consent
  • I have had the opportunity to ask questions
  • I voluntarily agree to proceed