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3d Consent Form

This document is a consent form for Extraoral (2D/3D) imaging procedures at Sri Aurobindo College of Dentistry. It outlines the types of imaging available, the purpose of the scans, and the patient's acknowledgment of the procedure, risks, and consent for use of data in medical research. It also includes a note regarding the recommendation against scans for pregnant women.

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41 views1 page

3d Consent Form

This document is a consent form for Extraoral (2D/3D) imaging procedures at Sri Aurobindo College of Dentistry. It outlines the types of imaging available, the purpose of the scans, and the patient's acknowledgment of the procedure, risks, and consent for use of data in medical research. It also includes a note regarding the recommendation against scans for pregnant women.

Uploaded by

cstsen092
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Sri Aurobindo College Of

Dentistry
SAIMS Campus, Indore- Ujjain State Highway, Bhawrasala, Indore (M.P.), India, Pin 453555

Department of Oral Medicine & Radiology


EXTRA ORAL (2D/3D) IMAGING CONSENT FORM
Name: - ________________________________________Age: ______ Sex M____F____
Date:-
Address: - _______________________________________________________________
OPD No. : _________________________ UHID NO. :- ___________________________

General description of Procedure:


An Extraoral scan(2D/3D view):
2D view- Panoramic radiograph (OPG), Lateral cephalogram, Pranasal sinus view (PNS), Submentovertex
view (SMV), Lateral oblique, reverse towne, TMJ views and others are techniques that depicts Orofacial
structures in two dimensional view.
3D view- A CBCT scan is usually referred to as Cone Beam Computed Tomography. This is an x-ray
technique similar to a medical CT scan. Your diagnosis and treatment planning can be enhanced by a more
complete understanding of complex 3-D anatomy. The relationship of anatomical structures in three
dimensions is important in assessing your condition as well as treatment planning for dental implants,
surgical extractions, endodontic treatment, oral surgery or advanced dental restorative procedures.
I Authorize _______________________________________________________________________ To
perform 2D/3D Imaging of _____________________________________________________________
Under the direction of Dr.

The doctor has fully explained me the procedure he will perform and has answered my questions about my
condition and the procedure to my satisfaction. The doctor has also explained the risk and I am willing to
undergo the procedure. This I consent to my own free act and will.
The doctor has also explained other methods of treatment to me and I have decided to undergo the
procedure. Including the radiation hazards, if necessary as the best means of trying to correct my condition
No guarantees have been given to me by my doctor about the results of the procedure and also understand
that there are times when more than one procedure may be necessary to complete the treatment of my
condition.
I agree to co-operate with the (concerned doctor and radiologist and follow their instructions to the best of
my ability
I also hereby give my consent for the use of my scans and data for medical research purpose.

Notes:- 2D/3D scans are NOT recommended for pregnant women because of danger to the fetus.
(Mark tick in appropriate column) : I am not pregnant I am pregnant

Patient's Signature _________________________

Date:__________________________ _______________________________
(Relationship, if available)

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