You're almost done!

Informed Consent

HOW DOES RESETSMILE WORK?

ResetSmile’s tooth replacement system is a BPA-free plastic temporary partial (“stayplate”) designed for the temporary replacement of missing teeth in partially edentulous patients. It fills in the spaces created by missing teeth and may act to restrict other teeth from shifting. Devices are intended to be worn without the aid of dental implants or preparation of the remaining natural teeth, instead using the natural teeth and tissues to retain and stabilize the device while being worn. The device is meant to be used as a temporary solution and is not a replacement for an in-person visit to a licensed dentist who can provide a comprehensive evaluation and definitive treatment options. ResetSmile is not intended to be worn as a long term/permanent dental appliance. Please contact the ResetSmile patient care team to discuss any concerns you may have with your device.

The devices are meant to temporarily help replace missing teeth to aid in the improvement of chewing and speaking until a permanent solution can be achieved. The device is a removable appliance that should be taken out daily after eating to be cleaned and completely removed at night time during sleep. The device should NOT be left in during sleep as it can be a choking hazard and provides no functional benefits during sleep.

RESETSMILE BENEFITS

AESTHETICS – ResetSmile is a discrete tooth replacement device, meaning the artificial materials used to fabricate it are intended to blend in with natural teeth and gums so that a reasonable aesthetic appearance may be achieved.

FUNCTION - In most cases, ResetSmile will establish an occlusal or “chewing” surface with opposing teeth. It may serve to reduce or restrict the drifting or movement of opposing teeth caused by a missing tooth.

COMFORT - ResetSmile devices are intended to be comfortable while wearing the appliance. Many ResetSmile patients who have worn other types of devices previously report increased comfort, speech and ability to taste when wearing their ResetSmile.

SPEECH - ResetSmile devices can improve your ability to pronounce certain words or vowels by providing additional teeth for phonetics.

DISCREET - The ResetSmile device is made of a tooth and gum-colored, BPA-free plastic. The devices are thin, light weight, flexible, and should ideally blend in with the rest of the oral cavity when worn - many people won't even know you're wearing them.

HYGIENE - Because the ResetSmile devices can be removed, you can eat, brush and floss normally, and the process of using ResetSmile may improve your oral hygiene habits.

RISKS

I UNDERSTAND that the process of fabricating and fitting stayplates includes risks and possible failures. Even though the utmost care and diligence is exercised in preparation for and fabrication of prosthetic appliances, there is the possibility of failure with patients not adapting to the dentures. I agree to assume those risks and possible failures associated with but not limited to the following:

FAILURE - Many variables may contribute to unsuccessful utilization of stayplates including (1) gum tissues which cannot bear the pressures placed upon them resulting in excessive tenderness and sore spots; (2) jaw ridges which may not provide adequate support and/or retention; (3) musculature in the tongue, floor of the mouth, cheeks, etc., which may not adapt to and be able to accommodate the artificial appliances; (4) excessive gagging reflexes; (5) excessive saliva or excessive dryness of mouth; (6) general psychological and/or physical problems interfering with success; (7) natural teeth to which devices are anchored (called abutment teeth) may become tender, sore, and/or mobile; (8) abutment teeth may decay or erode around the clasps or attachments; (9) tissues supporting the abutment teeth may fail.

BREAKAGE - Due to the types of materials which are necessary in the construction of these appliances, breakage may occur even though the materials used were not defective. Factors which may contribute to breakage are: (1) chewing on foods or objects which are excessively hard; (2) gum tissue shrinkage which causes excessive pressures to be exerted unevenly on the dentures; (3) cracks which may be unnoticeable and which occurred previously from causes such as those mentioned in (1) and (2); (4) dropping or applying forces to the denture aside from those occurring naturally inside the mouth during normal use. The above factors listed may also cause extensive denture tooth wear or chipping.

LOOSE DENTURES - Stayplates normally become less secure when there are changes in the supporting gum tissues or abutment teeth. Devices themselves do not change unless subjected to extreme heat or dryness. When a device becomes "loose" over time, a new one may be necessary. Denture adhesives may aid in securing “loose” devices but are not a replacement for a new, properly fitting device

ALLERGIES - Infrequently, the oral tissues may exhibit allergic symptoms to the materials used in construction of stayplates over which we have no control. If you experience a reaction, please discontinue use and inform us and your primary care provider immediately.

CAVITIES, GUM OR PERIODONTAL DISEASE - Cavities, tooth decay, periodontal disease, gingival recession, inflammation of the gums or permanent markings (e.g. decalcification) may occur or accelerate during use of removable appliances such as the ResetSmile device. These reactions are more likely to occur if you eat or drink lots of sugary foods or beverages, or do not brush and floss your teeth before inserting the devices, or do not routinely see a dentist for preventive check-ups. In addition, in some circumstances discoloration or white spots may occur; small cavities may increase in size, causing sensitivity and, in some cases, pain or tooth breakage; gingival inflammation may increase, causing soreness and/or bleeding. If underlying periodontal conditions persist unchecked, they may become more prevalent and lead to tooth loss. You may have to discontinue ResetSmile treatment. All of these symptoms will require you to seek care from a dentist of your choice.

SORE SPOTS - A stayplate may cause a sore spot and/or ulcer when first fitted. Visit your dental practitioner to check fit and possible readjustment.

NERVE DAMAGE IN TEETH - An injured tooth can die over a period of time with or without ResetSmile treatment and it may not be obvious that a tooth was previously injured. Nerve damage to an injured tooth may flare up from movement of pressure placed on teeth during therapy and may require root canal treatment. While this seldom occurs during ResetSmile treatment, if and when it does it is most frequently related to a previous accident or injury. It is not possible to predict which patients may experience nerve damage during ResetSmile treatment, but patients who have experienced tooth injury in the past or have restorative work on a tooth are at higher risk. If your regular dentist detects nerve damage prior to or during your ResetSmile therapy treatment, treatment may need to be discontinued or tooth loss can occur.

FAILURE OF SUPPORTING TEETH AND/OR SOFT TISSUES - Natural teeth supporting stayplates may fail due to decay; excessive trauma; gum tissue or bony tissue problems. This may necessitate extraction. The supporting soft tissues may fail due to many problems including poor dental or general health. Other dental restorations such as crowns, fixed bridges and/or implants may also be affected by the device.

PREVIOUS DENTAL TREATMENT - ResetSmile devices will not support or be attached to dental implants and may not be effective on patients who have certain dental restorations, such as bridges. Additionally, dental restorations, such as crowns, veneers, or bridges, may require replacement due to the utilization of a ResetSmile device.

UNCOMFORTABLE OR STRANGE FEELING - This may occur because of the differences between natural teeth and the artificial replacement devices. Most patients usually become accustomed to this feeling over time.

ORAL PIERCINGS - Piercings are contraindicated during ResetSmile therapy and therefore should be removed during treatment. In some circumstances, failure to do so could result in fractures, chips, or accidental attachment to the ResetSmile device or broken teeth leading to termination of your treatment.

AESTHETICS OR APPEARANCE - Stayplates will be fabricated using artificial materials to replace missing natural teeth. The dental team will make every attempt to restore natural aesthetics and a lifelike appearance to the patient, however artificial teeth may occasionally look different from a patient’s natural teeth.

TASTE ALTERATION - Artificial teeth may alter your taste of food, especially if the devices are not cleaned properly.

STAINING & ODORS - Staining on devices can occur, however this is minimized by good oral hygiene and avoiding such items as tobacco, coffee and tea. The plastic materials used in artificial tooth replacement are porous which can collect microscopic food debris and contribute to odors. Check with ResetSmile or your dental practitioner for a list of approved denture cleansers to maintain the cleanliness and appearance of your device.

FOOD TRAPS - The space(s) between the device and your gums may catch food during eating. The device should be removed for cleaning throughout the day by rinsing off food particles after eating and soaking in cleanser on a regular basis.

INHALING OR SWALLOWING - I understand there is a risk of aspirating (inhaling) or swallowing the device while in use.

TEMPOROMANDIBULAR JOINT DISORDER - Artificial tooth replacements may cause certain disorders involving the temporomandibular joint (TMJ). TMJ disorders may include headaches and neck pain, jaw pain, grinding or popping when moving the jaw, problems moving the jaw or ringing in the ears, dizziness, vertigo or ear pain.

SAFETY – ResetSmile devices or portions of the device may break, be swallowed or inhaled. You may also have an allergic reaction to the materials used in the devices.

GENERAL HEALTH PROBLEMS - Overall medical conditions such as bone, blood or hormonal disorders, and many prescription and non-prescription drugs (including bisphosphonates) can affect the health and longevity of the teeth and the outcome of your ResetSmile Device.

BITE ADJUSTMENT - Your bite may change during treatment and may result in temporary discomfort. Your bite may require adjustment after use of the ResetSmile device. Bite adjustments should ideally be made by an in-person dentist.

BLACK TRIANGLES - Teeth which have been overlapped or missing for long periods of time may be missing the gum tissue and may exhibit a "black triangle" below and between teeth when replaced with a ResetSmile device. The growth and improvement of the papilla and soft tissue may not be possible with a ResetSmile device alone and should be performed with an in-person dentist or dental specialist.

IMPRESSION TAKING - When taking physical dental impressions there is always a risk of causing damage to the teeth and gums. It is generally advised to not proceed with taking dental impressions when there are loose teeth, crowns, bridges or implants present in the mouth, severe undercut, divergent abutments or extreme path of draw concerns, or there is evidence of periodontal disease or infection. I acknowledge that the impression taking process may cause damage to my natural teeth and gums and that I am aware of these risks.

I understand that it is the patient's responsibility to seek attention when problems occur and do not lessen in a reasonable amount of time; also, to be examined regularly to evaluate the devices, condition of the gums, and the patient's oral health.

I understand that it is imperative that my dental care is overseen by an in-person licensed dentist who can take proper measurements and evaluate my periodontal health and other factors that can minimize oral health problems. I understand that without x-rays and regular dental care, existing and new problems may be exacerbated resulting in infections, tooth loss and temporomandibular joint problems.

ALTERNATIVES TO RESETSMILE

There are many alternatives when it comes to treating partially edentulous patients, many of which are long term, permanent solutions for missing teeth. Alternative treatments include long term, permanent removable partial dentures, non-flexible stayplates or temporary partials, fixed bridges and dental implants. Full arch treatment (full dentures, fixed/hybrid implant dentures, etc.) is also an option if the dental practitioner determines that the remaining natural dentition cannot be saved and teeth must be extracted. Refusal to treat edentulism is also an alternative to restorative dentistry.

CONTRAINDICATIONS TO RESETSMILE

While wearing a ResetSmile device is fairly non-invasive, your oral condition should ideally be healthy and exclude broken, decayed, or loose teeth. Upon the evaluation of a licensed dentist, you may be required or recommended to seek an in-person visit to a licensed dentist to remove or repair damaged teeth before proceeding with a ResetSmile device. Recommendations made by our Teledentists may include seeking additional radiographs, consent, extractions, repairs of decayed teeth, or removal of loose teeth. You may, at your own risk, decide to proceed against the recommendation of the Teledentist by signing additional consent forms and release of liabilities should you choose to continue with the fabrication and delivery of your device without taking such recommendations.

HEALTHY TEETH & GUMS

ResetSmile devices are most effective if your teeth and gums are healthy. It is your responsibility to routinely see a dentist prior to starting ResetSmile devices, to verify that your teeth and gums are healthy prior to using ResetSmile devices. It is also your responsibility to maintain and have follow-up dental care during and after ResetSmile treatment.

INDEMNIFICATION

To the fullest extent permitted by applicable law, you will indemnify, defend (at our option), and hold harmless ResetSmile and our officers, directors, agents, partners, licensors, employees and agents from and against any losses, liabilities, claims, demands, damages, expenses or costs (“Claims”) arising out of or related to: (a) your access to or use of the Services; (b) the Customer Content or Feedback; (c) your violation of these Terms; (d) your violation, misappropriation, or infringement of any rights of another (including intellectual property rights or privacy rights); or (e) your conduct in connection with the Services or the Customer Content. You will cooperate with ResetSmile in defending such Claims, and pay all fees, costs, and expenses associated with defending such Claims (including attorneys' fees). ResetSmile will have control of the defense or settlement, at ResetSmile's sole option, of any third-party Claims. This indemnity is in addition to, and not in lieu of, any other indemnities set forth in a written agreement between you and ResetSmile.

DISCLAIMERS

You expressly acknowledge and agree that your use of the Services and any content or materials provided therein or therewith (including the Third-Party Content and Third-Party Services) is at your sole risk. To the fullest extent permitted under applicable law, our Services, and any content or materials provided therein or therewith (including the Third-Party Content and Third-Party Services), are provided “as is” and “as available” without warranties of any kind, either express or implied. ResetSmile disclaims all warranties with respect to the foregoing, including implied warranties of merchantability, fitness for a particular purpose, title, and non-infringement. ResetSmile does not represent or warrant that our Services or any other content provided therein or therewith (including the Third-Party Content and Third-Party Services) are accurate, complete, reliable, current, or error-free or that access to our Services or any content provided therein or therewith (including the Third-Party Content and Third-Party Services) will be uninterrupted. While ResetSmile attempts to make your use of our Services and any content provided therein or therewith (including the Third-Party Content and Third-Party Services) safe, we cannot and do not represent or warrant that our Services or any content provided therein or therewith (including the Third-Party Content and Third-Party Services) or our servers are free of viruses or other harmful components or content or materials. You assume the entire risk as to the quality and performance of the Services. All disclaimers of any kind (including in this Section 11 and elsewhere in these Terms) are made for the benefit of all ResetSmile and ResetSmile’s respective shareholders, agents, representatives, licensors, suppliers, and service providers, as well as our and their respective successors and assigns.

LIMITATION OF LIABILITY

1. To the fullest extent permitted by applicable law, ResetSmile (and its affiliates, parent companies, directors, officers, agents, employees, partners, licensors, contractors, permitted successors and permitted assigns) will not be liable to you or any third party under any theory of liability (whether based in contract, tort, negligence, warranty, or otherwise) for any indirect, consequential, exemplary, incidental, punitive, special, moral, or exemplary damages whatsoever, including, without limitation, damages for lost profits, loss of data, business interruption or any other commercial damages or losses arising out of or related to this Agreement, including, without limitation, your inability to use the Services, whether or not damage was foreseeable and even if ResetSmile has been advised of the possibility of such damages and notwithstanding the failure of any agreed or other remedy of its essential purpose.
2. The total liability of ResetSmile for any claim arising out of or relating to this Agreement or our Services, regardless of the form of the action, is limited to the greater of: (i) Fifty Dollars (USD $50.00); and (ii) the amount paid by you to use our Services in the twelve (12) months preceding the claim.
3. Some jurisdictions do not allow the limitation of certain damages, in which case some of the limitations above may not apply to you.

DISPUTE RESOLUTION; BINDING ARBITRATION

Please read this Section carefully because it requires you and ResetSmile to arbitrate certain disputes and claims and limits the manner in which we can seek relief from each other. Arbitration precludes you and ResetSmile from suing in court or having a jury trial. You and ResetSmile agree that arbitration will be solely on an individual basis and not as a class arbitration, class action, or any other kind of representative proceeding. ResetSmile and you are each waiving the right to trial by a jury.

Follow the instructions below if you wish to opt out of the requirement of arbitration on an individual basis. No class or representative actions or arbitrations are allowed under this arbitration agreement.

1. Informal Dispute Resolution Prior to Arbitration. For any dispute or claim between you and ResetSmile relating to this Agreement or our Services, including any privacy or data security claims, (collectively, “Disputes”, and each a “Dispute”), you and ResetSmile agree to attempt to first resolve the Claim informally via the following process:
   • If you assert a Dispute against ResetSmile, you will first contact ResetSmile by sending a written notice of your Dispute to ResetSmile by email to support@resetsmile.com If ResetSmile asserts a Dispute against you, ResetSmile will contact you by sending a written notice of ResetSmile’s Dispute to you via email to the primary email address associated with your account.
   • If you and ResetSmile cannot reach an agreement to resolve the Dispute within thirty (30) days after you or ResetSmile receives the applicable notice, then either Party may submit the Dispute to binding arbitration as set forth below. The statute of limitations and any filing fee deadlines shall be tolled for thirty (30) days from the date that either you or ResetSmile first send the applicable notice so that the Parties can engage in this informal dispute-resolution process.
2. Disputes Subject to Binding Arbitration; Exceptions. Except for individual disputes that qualify for small claims court and any disputes exclusively related to the intellectual property or intellectual property rights of you or ResetSmile, including any disputes in which you or ResetSmile seek injunctive or other equitable relief for the alleged unlawful use of your or ResetSmile’s intellectual property or other infringement of your or ResetSmile’s intellectual property rights (“IP Disputes”), all Disputes, whether based in contract, tort, statute, fraud, misrepresentation, or any other legal theory, that are not resolved in accordance with Section 13(a) will be resolved by a neutral arbitrator through final and binding arbitration instead of in a court by a judge or jury. The arbitration shall be administered by the American Arbitration Association (“AAA”), according to the Federal Arbitration Act, 9 U.S.C. § 1, et seq., (“FAA”) and according to AAA’s Commercial Arbitration Rules and Mediation Procedures in effect at the time the Claim arose (the “Rules”), as modified by this Agreement. The arbitrator will have the authority to grant any remedy or relief that would otherwise be available in court. The remedies and reliefs rendered by the arbitrator may be confirmed and enforced in any court having jurisdiction. If you are a “Consumer,” meaning that you only use the Services for personal, family or household purposes, the then-current version of the AAA’s Consumer Arbitration Rules are the Rules applicable to Claims between Customer and ResetSmile, as modified by this Agreement. The Rules are available at the AAA website www.adr.org.
3. Arbitration Fees. Customer and ResetSmile will each be responsible for arbitration fees in accordance with the applicable Rules and this Agreement. If you are a Consumer and such costs are determined by the arbitrator to be prohibitive compared to litigation costs, ResetSmile will pay as much of Customer’s arbitration costs as the arbitrator finds is necessary to prevent arbitration from being cost-prohibitive (as compared to the cost of litigation).
4. Arbitration Procedure and Location. Customer or ResetSmile may initiate arbitration of any Claim not resolved during the informal resolution period by filing a demand for arbitration with AAA. Instructions for filing a demand for arbitration with AAA are available on the AAA website or by calling AAA at 800-778-7879. Customer will send any demand for arbitration to ResetSmile by certified mail addressed to 4200 W Royal Ln, Suite 125 Irving, TX 75063 or by email to support@resetsmile.com ResetSmile will send any demand for arbitration to Customer by certified mail or email using the contact information Customer has provided to ResetSmile.
5. Arbitrations will be conducted in the English language by a single arbitrator. Customer and ResetSmile agree that the arbitrator will be bound by this Agreement.
6. For Claims in which the claimant seeks less than USD $25,000, the arbitrator will decide the matter solely based on written submissions, without a formal hearing, unless the arbitrator decides that a formal hearing is necessary. For Claims in which the claimant seeks USD $25,000 or more, or smaller matters in which the arbitrator determines a hearing to be necessary, hearings will be conducted by video or telephone, unless the arbitrator determines an in-person hearing to be necessary. If an in-person hearing is required, the hearing will take place in the Central District of the State of California, unless the arbitrator determines that this would pose a hardship for Customer, in which case the location for any in-person hearing will be determined by the applicable Rules. The arbitrator (not a judge or jury) will resolve all Claims in arbitration. The arbitrator will make a decision in writing but need not provide a statement of reasons unless requested by either Party. An arbitration award, and any judgment confirming it, apply only to that specific case; it cannot be used or offered as precedent in any other case except to enforce the award itself unless ResetSmile and Customer agree prior to issuance of the award. Any arbitration decision or award may be enforced as a final judgment by any court of competent jurisdiction or, if applicable, application may be made to such court for judicial confirmation of any award and an order of enforcement.
7. One Year to Assert Claims. To the extent permitted by law, any Claim by Customer or ResetSmile against the other must be filed within one (1) year after the Claim arose; otherwise, the Claim is permanently barred, which means that Customer and ResetSmile will no longer have the right to assert that Claim.
8. Opting Out of Arbitration. You have the right to opt out of binding arbitration within thirty (30) days of the date you first accepted these Terms by providing us with notice of your decision to opt-out via email by certified mail addressed to:ResetSmile
   Attn: Legal Department – Arbitration Opt-Out
   4200 W Royal Ln, Suite 125
   Irving, TX 75063

   In order to be effective, the opt-out notice must include your full name, mailing address, and email address. The notice must also clearly indicate your intent to opt out of binding arbitration. By opting out of binding arbitration, you are agreeing to resolve disputes in accordance with Section 13.

9. Rejection of Future Arbitration Changes. You may reject any change we make to Section 13 (except address changes) by personally signing and sending us notice within thirty (30) days of the change by certified mail addressed to:ResetSmile
   Attn: Legal Department – Arbitration Opt-Out
   4200 W Royal Ln, Suite 125
   Irving, TX 75063

   If you do, the most recent version of Section 13 before the change you rejected will apply.

10. Severability. If any portion of this Section 13 is found to be unenforceable or unlawful for any reason, including but not limited to because it is found to be unconscionable, (i) the unenforceable or unlawful provision will be severed from these Terms; (ii) severance of the unenforceable or unlawful provision will have no impact whatsoever on the remainder of this Section 13 or the Parties’ ability to compel arbitration of any remaining claims on an individual basis pursuant to this Section 13; and (iii) to the extent that any claims must therefore proceed on a class, collective, consolidated, or representative basis, such claims must be litigated in a civil court of competent jurisdiction and not in arbitration. The litigation of those claims will be stayed pending the outcome of any individual claims in arbitration. Further, if any part of this Section 13 is found to prohibit an individual claim seeking public injunctive relief, that provision will have no effect to the extent such relief is allowed to be sought out of arbitration, and the remainder of this Section 13 will be enforceable.

GOVERNING LAW

Any claims will be governed by and construed and enforced in accordance with the laws of the State of Texas, except to the extent preempted by U.S. Federal Law, without regard to conflict of law rules or principles (whether of the State of Texas or any other jurisdiction) that would cause the application of the laws of any other jurisdiction. If any claim is not subject to arbitration pursuant to Section 13, then the state and federal courts located in the Northern District of the State of Texas, will have exclusive jurisdiction. You and ResetSmile waive any objection to venue in any such courts. If your local law requires that consumer contracts be interpreted subject to local law and enforced in the courts of that jurisdiction, this section may not apply to you only to the extent that local law conflicts with this section.

CONFIDENTIALITY

ResetSmile and Customer may disclose to each other information identified at the time of disclosure as confidential or which should be reasonably known by the receiving Party to be confidential (“Confidential Information”). The Services and other ResetSmile Technology are the Confidential Information of ResetSmile, and Customer Content is the Confidential Information of Customer, in each case without any marking or further designation. Except as authorized herein, the receiving Party will (i) hold in confidence and not disclose any Confidential Information of the disclosing Party to third parties, and (ii) not use Confidential Information of the disclosing Party for any purpose other than fulfilling its obligations and exercising its rights under this Agreement. The receiving Party may disclose Confidential Information to its representatives having a need to know, provided that such representatives are bound to confidentiality obligations no less protective of the disclosing Party than this Section and that the receiving Party remains responsible for compliance by any such representative with the terms of this Section. These restrictions on disclosure will not apply to any information which: (a) is or becomes generally known or publicly available through no act or omission of the receiving Party; (b) is known by the receiving Party without confidentiality restriction at the time of receiving such information, as shown by written records; or (c) is furnished to the receiving Party by a third party without confidentiality restriction. The receiving Party may make disclosures to the extent required by law or court order, provided the receiving party notifies the disclosing Party in advance and reasonably cooperates in any effort to obtain confidential treatment. The receiving Party acknowledges that disclosure of the disclosing Party’s Confidential Information would cause substantial harm for which damages alone would not be a sufficient remedy, and therefore that upon any such disclosure by the receiving Party the disclosing Party will be entitled to seek appropriate equitable relief in addition to whatever other remedies it might have at law.

TELEHEALTH/TELEDENTISTRY

PURPOSE - The purpose of this form is to obtain written consent for the participation in a system of dental care called “Teledentistry.” This system offers limited dental treatment, evaluation, consultation, and recommendations to be made in an “off-site” location rather than in a dental office or dental clinic. Delivery of care through this system would involve electronic communication with a licensed dentist who will be remotely assessing and evaluating a patient’s care with the assistance of licensed hygienists and auxiliary staff. Services provided under this system include Teledentistry consultation and standard dental hygiene and dental office procedures.

OVERVIEW OF TELEDENTISTRY What is Tele-Dentistry? Teledentistry falls under a broader category of Telehealth. Telehealth is not a specific service; it refers to a broad variety of technologies and tactics to deliver virtual medical, health, and education services. As an umbrella term, it is further defined when applied to specific health care disciplines, such as dentistry.

Teledentistry, according to the ADA’s Comprehensive Policy Statement on Teledentistry, refers to the use of telehealth systems and methodologies in dentistry. Teledentistry can include patient care and education delivery using, but not limited to, the following modalities:

• Live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology.
• Synchronous teledentistry (D9995) is delivery of patient care and education where there is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.
• Store-and-forward (asynchronous): Transmission of recorded health information (for example, radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to a practitioner, who uses the information to evaluate a patient’s condition or render a service outside of a real-time or live interaction.
• Asynchronous teledentistry (D9996) is different as there is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. Also known as store-and-forward, asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time.
• Remote patient monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support of care.
• Mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants (PDA)

Teledentistry is a new way to provide care for patients who do not want to or cannot go to the dentist’s office. Teledentistry uses electronic dental records including x-rays, photographs, data collection, health and other history information. These records or other electronic communications are either sent to the dentist offsite in real-time or they are stored and shown to a dentist after the initial appointment is over requiring a follow-up appointment. They are retained for the dentist in electronic form and forwarded to him/her for review at a later time. The goal of a Teledentistry system is to have the dentist create a diagnosis and recommendations for you and your dental care without the dentist physically being present with you in person.

BENEFITS OF TELEDENTISTRY - The benefits of Teledentistry include having access to a dentist and additional dental information without having to travel to a dental office or clinic. During the visit, the patient may receive advice and recommendations from a dentist who is not physically present but can see during the evaluation much of the same information that would be collected and evaluated in person. This dental service can be utilized for an initial consultation, for a follow-up consultation or exam, and/or for problem-focused evaluations and recommendations. Teledentistry may also be beneficial for emergency situations that can be addressed with quick and immediate consultation with a trained dental professional without requiring travel to the dental office or dental clinic. The patient may benefit from saving time and money by choosing to utilize Teledentistry as a means to receive recommendations and evaluation by a dentist in the comfort of his/her location of choice.

RISKS OF TELEDENTISTRY - A potential risk of Teledentistry is that a face to face consultation with a dentist may still be necessary after the Teledentistry appointment. This could be due to the patient’s specific medical condition or for other reasons that would require a direct and in person examination or treatment. Recommendations will be made to you or the patient about future care after the Teledentistry consultation or examination is complete and could include recommendations about whether or not to see a dentist in a dental office or dental clinic.

Other risks involved in Teledentistry include but are not limited to inability of the dentist to physically touch the patient and feel certain parts of the mouth or face with his or her hands resulting in more of a limited scope of information. Future dental visits may be needed, even if one is not recommended at this time. The recommendations may change if more information about the patient's dental needs become known. Other risks include potential corruption of data through the transmission or complete loss of the electronic health records due to possible software or hardware glitches.

The practice of dentistry is not an exact science therefore any specific results CANNOT be guaranteed and there is an inherent risk with any dental procedure, diagnosis, and recommendation. Teledentistry does NOT diminish these risks and while every reasonable measure may be taken by your clinician, no guarantees are made as to the results, accuracy, or efficiency of the diagnosis or treatment.

ALTERNATIVES TO TELEDENTISTRY - The alternative to Teledentistry consultations is a live face-to-face visit with a dentist. At any time you or the patient can choose to get dental care in a dental office or dental clinic and a copy of the patient’s entire chart and data will be provided to you or your new dentist.

CONFIDENTIALITY: Current federal and state laws about confidentiality apply to the information used or disclosed during your Teledentistry consultations. You will be provided with a separate document which describes how your private information will be handled. This is known as the “Notice of Privacy Practices.” You will also be offered a copy of this form to keep. Your personal health data nor identity will not be disclosed without separate consent, except as specifically described in this form or required by law.

RIGHTS - You may choose not to participate in Teledentistry consultations at any time before and/or during the consultation. If you decide not to participate in a Teledentistry consultation it will not affect your right or ability to future care or treatment but would require you to travel to a dental office or dental clinic to perform the examination and/or portions of your treatment. You have the option to seek a dental consultation or treatment in a dental office at any time before or after the Teledentistry consultation. If an injury occurs as a result of procedures provided by the RDA, RDH, OR RDHAP, notify that person. They will make arrangements for the appropriate treatment of the injury as would be the case in a traditional dental setting.

INFORMED CONSENT

TELEHEALTH – I hereby consent to use ResetSmile’s 3rd party teledentistry platform so a state-licensed dentist and I can engage in telehealth as part of my tooth replacement treatment. I understand that "telehealth" includes the practice of health or dental care delivery, diagnosis, consultation, treatment, and transfer of medical/dental information, both orally and visually, between me and a state licensed dental professional who has engaged ResetSmile to provide certain non-clinical dental support organization services.

By signing this Informed Consent, I understand that I am certifying that: During my most recent visit, my dentist has cleaned my teeth and has checked for and repaired cavities, loose or defective fillings, crowns or bridges. My dentist assessed me for dental nerve damage. My dentist checked my last x-rays or has otherwise verified that I have no shortened or resorbed roots or impacted teeth. My dentist has probed or measured my gum pockets and confirmed that I do not have periodontal or gum disease. My dentist performed a full oral-cancer screening and confirmed that I do not have oral cancer. I confirm that I do not have pain in any of my teeth or jaws. I further confirm that none of my teeth are loose, that I do not have any “baby teeth” and that all of my permanent teeth are present. I further consent to ResetSmile sharing my personal and medical information with third parties, business associates, or affiliates for the purposes of tooth replacement treatment planning and/or manufacturing purposes.

I certify that I can read and understand English. I have read this form and fully understand the benefits and risks listed in this form related to my use of ResetSmile Device. I understand that ResetSmile contracts with professional corporations which have engaged licensed dentists and dental professionals in the state in which I reside. I hereby provide my consent for one or more of the dentists or dental professionals affiliated with that professional corporation to review my records for potential evaluation, diagnosis, and treatment. I understand that my acceptance of the treatment plan approved by my treating dentist and planned by ResetSmile prior to the onset of treatment reflects the results I expect to achieve. I understand that my treatment plan may have to be modified and as a result, I may have to undergo adjustments (“touch-ups”) during my therapy to achieve results that maximize comfort, aesthetics and function. I also understand that neither the dentist who prescribes my ResetSmile treatment nor ResetSmile can, with certainty, predict the events that may lead to touch-ups and adjustments. I further understand that my treatment will only address a small set of indications and will not treat certain situations such as full arch missing teeth or edentulous areas with 4 or less retainer teeth remaining. In order to replace missing teeth in certain situations, I will need to seek more comprehensive treatment via my local dental professional. I understand that the dentist who prescribes my ResetSmile device will determine recommendations for treatment for me and that I may be recommended to see an in-person dentist instead of utilizing ResetSmile devices. Lastly, I understand that for tooth replacement therapy to achieve results that are acceptable, I must be compliant with the treating dentist’s prescribing instructions, recommendations including those that are required via touch-ups, if applicable.

I hereby authorize ResetSmile’s use of photographs taken of me, including certain personal health information such as my first name and likeness, for educational and/or marketing purposes, which may result in disclosure to the general public. I acknowledge this authorization is voluntary, I will receive no financial compensation, and my participation in ResetSmile therapy or tooth replacement treatment does not confer upon me any right of ownership in such photographs. I hereby release ResetSmile and its Teledentistry partners from any and all liability for any copyright, trademark, or other intellectual property-related claims by me or any third party in connection with tooth replacement treatment. I also understand (i) my treatment is not conditioned on my authorization of ResetSmile’s use of my name or likeness, (ii) I have the right to access, inspect, and receive a copy of any such photograph used by ResetSmile, and (iii) I can refuse to provide or otherwise revoke such authorization by contacting ResetSmile at support@resetsmile.com. This authorization is valid in perpetuity from the date of my consent hereto, unless earlier revoked in the manner prescribed above.

Data Aggregation, Anonymization, and De-Identification. I understand that ResetSmile will use, reproduce, aggregate, and modify my images and/or data to (i) create aggregated data, (ii) create de-identified or anonymized data, as described in local jurisdictional privacy laws, for the purpose of supporting ResetSmile’s research, development, and quality improvement purposes. Further, all rights, titles, and interest in the aggregated data, and all intellectual property rights therein, belong to and are retained solely by ResetSmile. In the event that the ResetSmile affiliated doctor who reviews my chart and other information that I submit determines that I am not an appropriate candidate for the ResetSmile tooth replacement treatment, but that I am a candidate for more advanced tooth replacement treatment, I hereby consent to having all of my records in ResetSmile's possession (including without limitation dental impressions, digital scans, photographs, and medical history documentation) sent to a licensed dentist or dental professional for further review and treatment planning, and I agree to being contacted directly by that dental provider.

I have read and understand the information in this document and accept the potential risks, benefits, and liabilities that arise from utilizing Teledentistry and ResetSmile services. I have read the risks, benefits, facts and information provided above and have been given a copy of the Notice of Privacy Practices. I understand that my medical/dental information and electronic health records will be transmitted to an offsite licensed dentist who will evaluate this information in order to assess my current condition and needs and use this information to give recommendations based on his/her comfort level and best judgment. I also understand that at any time I have the option to seek direct face-to-face consultation by a dentist in a dental office or dental clinic before, during, or after my ResetSmile therapy. I have had an opportunity to ask questions about this information and all of my questions have been answered. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment I have requested and authorized.

Patient Name:

Signature:

Date:

Location:

Patient Information, Dental & Medical History

WHY DO I NEED TO SHARE MY MEDICAL HISTORY AND DENTAL HISTORY WITH RESETSMILE?

Many diseases, medications and medical and dental conditions can have an effect not only on your overall health but also on how your teeth and gums will respond to tooth replacement with a removable dental prosthetic. A ResetSmile dental professional has all four years of doctoral and post-doctoral graduate education and is trained to utilize the information you provide in your health history to ensure you are a viable candidate for ResetSmile and that your teeth and body are currently in optimal health to maintain your device. Please keep our team updated if you have any changes to your medical or dental history during your treatment. Your medical and dental history by law is confidential and will not be released to any other entity or doctor without your written request.

AUTHORIZATION AND RELEASE FORM

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health and that I assume all responsibility for any adverse effects that are the result of providing false or inaccurate information. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Patient Name:

Signature:

Date:

Location: