A CT scan — also called CT or computerized tomography — is an X-ray technique that produces images of your body that visualize internal structures in cross section rather than the overlapping images typically produced by
conventional X-ray exams.

A conventional X-ray of your mouth limits your dentist to a 2-D visualization. Diagnosis and treatment planning can
require a more complete understanding of a complex 3-D anatomy. CT examinations provide a wealth of 3-D
information that can be used when planning for dental implants, surgical extractions, maxillofacial surgery
and advanced dental restorative procedures.


CT scans are NOT recommended for pregnant women because of danger to the fetus.


Initial below as appropriate:



___I am pregnant          ___I am not pregnant     ___I am unsure whether I am pregnant


                                                      

                                                         Risks associated with this procedure


CT scans, like conventional X-rays, expose you to radiation. The amount of radiation you will be exposed to by the CT scan used by this office is approximately the equivalent to the exposure you would get from 3 to 5 days in the sun. An alternative to CT scans is conventional X-rays. While parts of your anatomy beyond your mouth and jaw may be evident from the scan, Clear 3D Imaging is not qualified to diagnose conditions that are present in those areas nor will we be looking for any abnormal conditions. Therefore, the mere fact that structures are evident on the scan does not mean that they are being examined by a professional to determine whether they are normal.  If you would like to have your scan reviewed, your dentists can request that a report from a Certified Radiologists can be included with your scan for an additional fee.


I, _____________________, certify that I have read the above and that I understand the procedure to be performed and its benefits, risks and alternatives.  I acknowledge that I have been a full opportunity to discuss this matter with Dr. ________________ and have my questions answered.  I hereby freely and willingly consent for Clear 3D Imaging to perform the following radiographic procedure:


           1 Cone Beam Computed Tomography


______________________________              

Patient's Name


______________________________

Name of parent or legal guardian if patient is under 18 years of age


______________________________                ________________

Signature of patient or legal guardian            Date    


____________________________

Witness


The Dental Care Center and Clear 3D imaging are owned in partnership by Higgins, Mani and Watson, DDS.



Consent Form