Consent only CBCT / OPG information consent Form

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

Patients Name: *

Date Of Birth *

I have a current Medicare Card *

YesNo - I understand there may be extra charge to have a radiologist to report on my scan.

Medicare Card Number

Position on Card

Risks: Scans, like conventional x-rays, expose you to radiation. The amount of background radiation received is dependent on various factors. Radiation in pregnancy, although not recommended, is sometimes required and extra precautions can be taken to ensure minimal risks to your unborn babies development

Computerised Tomography, also known as a CBCT scan or Cone Beam scan is an x-ray that produces three-dimensional images of your jaw bone, teeth and surrounding structures which cannot be obtained with conventional radiography, which limits your practitioner to a 2D view. Diagnosis and treatment planning can require 3D images of your anatomy. CBCT examinations provide a wealth of information which may be used when planning for dental implants, surgical extractions, maxillofacial surgery and advanced dental restorative procedures.

Orthopantomogram, also known as a (OPG) this is a panoramic 2D dental radiograph of the upper and lower jaw

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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