Computerised Tomography (Cone Beam/CBCT Scan ) Information and Consent Form

Computerised Tomography (Cone Beam/CBCT Scan ) Orthopantomogram (OPG) Information and Consent Form

Patients Name: *

Patient Email:

Title: *

First Name *As listed on Medicare Card

Last Name *As listed on Medicare Card

Date Of Birth *

Address: *

Street address *

Suburb *

State *

Postcode *

Medicare Card Number *

Reference Number *

Expiry Date: (please use last day of the month) *

Female Patients please answer:

I am PregnantNot PregnantPossibility of Pregnancy

Do you have a history of thyroid cancer? *

YesNo

PATIENT CONSENT:

By providing my signature, I certify that I understand the recommended treatment, and I have had all of my questions answered. I have not been offered any guarantees.

I herby consent to any updated (if required) extra oral radiopgrphs to be taken within the next 24 months.

Sign Here: *

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Clinical Information

Date of Scan *

Type Of Scan:: *

Reason For Referral:: *

Site of Interest: Please provide PDF slices of listed site.

Further Information

Practitioners signature *

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Operator: *Staff who took scan please initial

Referring Practitioners Name:: *