CBCT Consent Form

Imaging Consent

Why CBCT May Be Recommended

Cone beam CT imaging can help evaluate anatomy, bone, teeth, and surgical planning needs in selected cases.

• Dental implant planning
• Impacted tooth evaluation
• Jaw or bone assessment
• Complex surgical planning

Imaging Consent

Purpose Of The Scan

A CBCT scan is a three-dimensional imaging technique used to provide a detailed view of dental and facial structures. It may be necessary for accurate diagnosis and treatment planning for a specific case.

Imaging Consent

Benefits, Radiation Risk, And Alternatives

The CBCT consent form explains the diagnostic benefits of three-dimensional imaging, including improved accuracy, identification of critical nerves and sinus locations, and more predictable surgical planning. It also explains that CBCT uses a small dose of ionizing radiation and that the office follows the ALARA principle, meaning radiation exposure is kept as low as reasonably achievable.

• Benefits may include improved diagnostic accuracy
• Risks include exposure to a small dose of ionizing radiation
• Alternatives may include 2D imaging such as panoramic or periapical X-rays
• 2D imaging may not provide enough information for some treatment plans

Imaging Consent

Consent And Interpretation

The CBCT consent form explains the reason for the scan, benefits, radiation risk, alternatives, professional interpretation, and reporting timeline. It notes that the scan may be interpreted in-house or securely transmitted to Canaray Oral & Maxillofacial Radiology for a specialist report when required.

• Formal radiologic review may be required
• Reports may be completed in approximately 10 to 14 business days
• Significant findings may be shared with the referring dentist for follow-up
• Patients should disclose pregnancy possibility before imaging

Imaging Consent

Privacy And Financial Responsibility

The form explains imaging fees, patient responsibility, privacy, secure data transfer, and authorization to share imaging information for diagnosis and treatment planning. It states that imaging data is handled according to Ontario's Personal Health Information Protection Act and may be securely shared with the referring dentist or radiology provider.

Imaging Consent

Fees And Professional Report

The CBCT form explains that the scan and professional interpretation fee is the patient's responsibility at the time of service, regardless of insurance coverage. The scan cost includes mandatory professional review when required by the office process.

Imaging Consent

Consent, Pregnancy Disclosure, And Right To Withdraw

Patients are asked to confirm that they have read and understood the CBCT consent form, including benefits, risks, alternatives, mandatory reporting requirements, privacy and data transfer terms, financial responsibility, pregnancy disclosure, and the right to withdraw consent before the scan is performed.