CBCT Consent Form – Dr Kevin J. McCann

CBCT 3D Imaging Informed Consent Form

Informed Consent for CBCT 3D Imaging

Patient Information

Patient First Name(Required)

Last Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Patient Email(Required)

Referring Dentist(Required)

Date(Required)

DD slash MM slash YYYY

Reason for Scan

Reason for Scan(Required)

Please fill below

Purpose of the Scan

A Cone Beam Computed Tomography (CBCT) scan is a 3D imaging technique used to provide a detailed view of your dental and facial structures. This is necessary for accurate diagnosis and treatment planning for your specific case.

Benefits and Radiation Risk

a) Benefits: Increased diagnostic accuracy, identification of critical nerves and sinus locations, and more predictable surgical outcomes.

b) Risks: This procedure involves exposure to a small dose of ionizing radiation. This facility follows the ALARA (As Low As Reasonably Achievable) principle to ensure you receive the lowest dose possible for a high-quality image.

c) Alternatives: 2D imaging (Panoramic/Periapical). I understand that 2D images may not provide sufficient information to safely complete my proposed treatment.

Mandatory Professional Interpretation

To ensure the highest standard of care and to screen for any abnormalities (incidental findings) outside the area of dental interest, every scan performed at this facility requires a formal radiologic report.

a) Review Process: Your scan will be interpreted by a qualified practitioner in-house or securely transmitted to Canaray Oral & Maxillofacial Radiology for a specialist report.

b) Reporting Fee: The cost of the scan includes this mandatory professional review.

c) Timeline: Formal reports typically take ten to fourteen (10-14) business days. You will be notified of any significant findings that require further medical or dental consultation.

d) Incidental Findings: Any incidental findings identify in the radiologic report will be communicated to the Referring Dentist listed above, who is responsible for any required follow-up or referral.

Fees & Financial Responsibility

The total fee for the CBCT scan and professional interpretation is $CAD:

CBCT Scan and Professional Interpretation Fee (CAD $)(Required)

I understand that I am responsible for this fee in full at the time of service, regardless of my insurance coverage.

Privacy and Data Transfer

Your digital imaging data will be handled in accordance with Ontario’s Personal Health Information Protection Act. By signing below, you authorize the secure electronic transfer of your imaging data to Canaray Oral & Maxillofacial Radiology (if required) and to the Referring Dentist listed above for the purposes of diagnosis and treatment planning. Imaging data will be retained in accordance with applicable Ontario regulatory requirements.

Pregnancy Disclosure

I have informed the clinic if there is any possibility that I am currently pregnant.

Pregnancy Disclosure(Required)

Not Pregnant

N/A

Right to Withdraw Consent

I understand that I may withdraw this consent at any time prior to the scan being performed. If I wish to withdraw my consent, I will inform clinic staff before the scan begins.

Patient Acknowledgement and Consent

I confirm that I have read and understood this consent form, including the benefits, risks, alternatives, and mandatory reporting requirements associated with CBCT imaging. My questions have been answered to my satisfaction. I consent to professional interpretation of my scan and, where required, to the secure transfer of my imaging data to Canaray Oral & Maxillofacial Radiology and to the Referring Dentist listed above.

Patient Consent Confirmation(Required)

I confirm that I have read and understood this consent form, including the benefits, risks, alternatives, mandatory reporting requirements, professional interpretation, privacy/data transfer terms, and financial responsibility. I consent to proceed with CBCT imaging.

Patient / Guardian Signature

I am signing this form as:(Required)

Patient/Guardian

Substitute Decision-Maker (SDM)

Patient/Guardian Signature(Required)

Print Name(Required)

Date(Required)

DD slash MM slash YYYY

Substitute Decision-Maker (SDM)

If signing as substitute decision-maker (SDM):

SDM Name(Required)

Relationship(Required)

Authority(Required)

Parent/Guardian

Power of Attorney for Personal Care

Other

Witness / Clinic Signature

Witness/Clinic Signature

Print Name

Date

DD slash MM slash YYYY