DEMO DO NOT ENTER DATA

PRE VISIT FORMS

Please enable JavaScript in your browser to complete this form.

1MEDICAL HISTORY QUESTIONNAIRE

2CANCELLATION POLICY

3INFORMED CONSENT FOR CONE BEAM CT SCAN

INFORMED CONSENT FOR CONE BEAM CT SCAN

(1) A Cone Beam CT scan is an x-ray technique that produces 3D images of your teeth and jaws that allows for visualisation in cross section rather than as overlapping images typically produced by conventional x-ray examination.
(2) Advantages of a CBCT scan include:
- More accurate diagnosis with greater chance of detecting conditions such as dental infections and root fractures that may otherwise be missed on conventional x-rays.
- Greater chance of providing information which may result in the patient avoiding unnecessary and sometimes invasive dental treatment.
- Helps the dentist see what needs to be done before commencing treatment.
- Higher accuracy when planning root canal treatment, more predictable outcomes, and faster treatment.
(3) Radiation: CBCT scans, like conventional x-rays, expose you to a low level of radiation. There are certain inherent and potential risks from radiation. The dose per CBCT scan is equivalent to several days of normal background environmental radiation and is considered safe. An alternative to a CBCT scan is reliance on conventional dental x-rays alone, however this has the limitations previously noted.
(4) Diagnosis of non-dental conditions: While parts of your anatomy beyond your mouth may be visible on the scan, we are neither physicians nor radiologists and will not make assessments concerning your anatomy beyond your mouth. We provide the scan for the purpose of dental evaluation only. Dentists are not qualified to diagnose all conditions that may be present.
(5) Women and pregnancy: CBCT scans are NOT recommended for pregnant women.

Pregnant Question

I am not pregnant.
I am pregnant.
I am unsure whether I am pregnant.

DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT, AND AGREE WITH WHAT IT SAYS

I certify that I have read this consent form. I understand the procedure to be performed, and its benefits, risks and alternatives. I acknowledge that I have had the opportunity to discuss the procedure with Drs Young, Dang, Wu or Wang or their designee, and have had any/all questions answered to my satisfaction. Thus, I give consent to Drs Young, Dang, Wu, or Wang and their designated staff to perform the CBCT scan.

Signature (or Initials) of Patient or Legal Guardian

Name

Date

DEMO DO NOT ENTER DATA

PRE VISIT FORMS

Medical History Questionnaire

Emergency Contact

PLEASE PROVIDE INFORMATION ABOUT THE FOLLOWING

If yes, please give further details. Specifically, is there any history of the following (please Tick):

At Sydney Endodontic Centre our specialist endodontists are actively involved in teaching students and dentists.

The above information, prepared for Sydney Endodontic Centre, is to the best of my knowledge true and correct.

CANCELLATION POLICY

INFORMED CONSENT FOR CONE BEAM CT SCAN

Pre Visit Forms

DEMO DO NOT ENTER DATA

PRE VISIT FORMS

Medical History Questionnaire

Emergency Contact

PLEASE PROVIDE INFORMATION ABOUT THE FOLLOWING

If yes, please give further details. Specifically, is there any history of the following (please Tick):

At Sydney Endodontic Centre our specialist endodontists are actively involved in teaching students and dentists.

The above information, prepared for Sydney Endodontic Centre, is to the best of my knowledge true and correct.

CANCELLATION POLICY

INFORMED CONSENT FOR CONE BEAM CT SCAN