DEMO DO NOT ENTER DATA PRE VISIT FORMS Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1MEDICAL HISTORY QUESTIONNAIRE2CANCELLATION POLICY3INFORMED CONSENT FOR CONE BEAM CT SCANMedical History QuestionnaireName *FirstLastPreferred NameDate of Birth *Address *Suburb *StatePostal Code *CountryHome PhoneWork PhoneMobileEmail * Emergency Contact Name *Relationship *Contact Number * PLEASE PROVIDE INFORMATION ABOUT THE FOLLOWING Do you or have you ever taken medication for osteoporosis or other bone conditions e.g. Fosamax, Prolia, Actonel? *NO (Do you or have you ever taken medication for osteoporosis or other bone conditions)YES (Do you or have you ever taken medication for osteoporosis or other bone conditions)Further Information If yes, please give further details. Specifically, is there any history of the following (please Tick):Medical ConditionsAnaemiaHepatitis AAnginaHepatitis BArthritisHepatitis CAsthmaHigh Blood PressureBlood DisordersHIVCancerKidney TroubleDepression / AnxietyOsteoporosisDiabetesPaget’s DiseaseEpilepsy / FitsPalpitationsExcessive BleedingRadiation TreatmentFainting SpellsRheumatic FeverHeart AttackSinus TroubleHeart MurmurStomach UlcerHeart SurgeryStrokeHeart TroubleThyroid ProblemsFurther InformationAre you taking any medication? *NOYESIf so, please give the name and dosageDo you have any allergies? (e.g. to drugs or latex/rubber) *NOYESFurther InformationAre you pregnant or breastfeeding? *NOYESFurther InformationDo you have a cardiac pacemaker? *NOYESFurther Information Is there anything else about your health that we should know? *NOYESFurther InformationAt Sydney Endodontic Centre our specialist endodontists are actively involved in teaching students and dentists.Please indicate if you give permission for de-identified photographs and x-ray imaging to be used for teaching purposes. *I DO give permissionI Do NOT give permissionThe above information, prepared for Sydney Endodontic Centre, is to the best of my knowledge true and correct.Signature (please enter your Initials) *Date *Next CANCELLATION POLICY We understand that you may need to cancel your appointment under certain circumstances. To ensure that all patients are given the opportunity to access our services with minimal waiting times, we have a cancellation policy in place. Where you need to cancel or reschedule your appointment please contact us at least two working days prior. Where there has been less than two working days' notice to cancel or reschedule your appointment, a $90 cancellation fee will be incurred. This means that if an appointment is cancelled or rescheduled the day prior, then the fee will apply. Where you do not contact us prior to your appointment advising that you will not be attending, you will be charged $90. By signing below, you confirm that you have read, understand, and have agreed to the Sydney Endodontic Centre Cancellation Policy Signature (please type Initials) *Date *PreviousNext INFORMED CONSENT FOR CONE BEAM CT SCAN 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. 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. 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. 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. 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. Thus, I give consent to Drs Young, Dang, Wu, Wang or HA and their designated staff to perform the CBCT scan. Signature (or Initials) of Patient or Legal Guardian Initials) Signature Are Name *Date *PreviousSubmit
