Consent for CT Scan Women
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 2D visualization. Diagnosis and treatment planning can require a more complete understanding of complex 3D anatomy. CT examinations provide a wealth of 3D information which may be used when planning for dental implants, surgical extractions, maxillofacial surgery, and advanced dental restorative procedures. One benefit of CT scans is the greater chance for diagnosing conditions, such as vertical root fractures, which can be missed a significant percentage of the time on conventional films, and which may result in the patient avoiding unnecessary additional treatment. In a nutshell, the CT scan enhances your dentist's ability to see what he/she needs to see before treatment is started. 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: 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 ___ 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, your dentist is not qualified to diagnose conditions that may be present in those areas, nor will your dentist be looking for any abnormal conditions other than those normally diagnosed by a dentist involving the area of the mouth and jaw. Therefore, the mere fact that other structures may be evident
DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT AND AGREE WITH WHAT IT SAYS I, _______________________, being 18 years or older, certify that I have read the above in the presence of __________________, and that I understand the procedure to be used and its benefits, risks and alternatives. I acknowledge that I have had a full opportunity to discuss this matter with Dr. ________________ and have my questions answered and give my consent to have Dr._____________ and his staff as he may designate, perform a CT scan. Signature of Patient or Legal Guardian____________________ Date_______________
Witness: __________________________ Date_________________________
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