By signing below, I certify that the information above is accurate and complete to the best of my knowledge.

Requesting Doctor: Tareq Beck, DMD

What is a CBCT Scan:
This is also known as a cone beam computerized tomography, is an x-ray technique that produces 3D (3 dimensional) images of your skull allowing for visualization of internal bony structures in cross section (rather than as overlapping images typically produced by a conventional x-ray). CBCT scans are primarily used to visualize bony structures, such as teeth and your jaw, not soft tissues such as your tissue or tongue.

Advantages of CBCT Scan over a conventional x-ray:
A conventional x-ray of your jaw limits your dental professional to a 2 dimensional/2D visualization. Treatment planning and diagnosis can require a more complete understanding of complex 3D anatomy. CBCT examinations provide a wealth of information which may be used when planning for dental implants and surgical extractions.

Radiation:
CBCT scan, like conventional x-rays, expose you to radiation. The amount of radiation used for CBCT examinations is carefully controlled to ensure the smallest possible amount is used that will still give a useful result. The dosage per scan is equivalent to 2 regular dental x-rays. The advantages of a CBCT scan outweigh the disadvantages.

Pregnancy:
Women who are pregnant should not undergo a CBCT scan due to the potential exposure to the fetus. Please inform your doctor if you are pregnant or planning to become pregnant.

Diagnosis of non-dental conditions:
While parts of your anatomy beyond your mouth and jaw may be visualized in the scan, your doctor may not be qualified to diagnose conditions that may be present in the head and neck beyond the dental zone. A CBCT may show evidence of disease of the cervical spine, skull or arteries. If any abnormality, asymmetries, or common pathological conditions are noted upon the CBCT scan, it may become necessary to send the scan to a maxillofacial radiologist for further diagnosis. However, by signing this form, you are acknowledging that your doctor may not be qualified to diagnose all conditions that may be present, and that his/her liability only extends to the limits of the dental zone of the scan and its interpretation for that purpose. We are not responsible for interpretation or evaluation of the scan, but are only providing the scan for evaluation at our office.

 

BY SIGNING THIS FORM, YOU AGREE TO ACCEPT THE RISKS AND ADVANTAGES NOTED.

I certify that I have read the above statement. I understand the procedure to be used and its benefits, risks, and alternatives. I have been given the opportunity to have my questions answered, and accept the risks of the CBCT scanning procedure as described. I therefore give my consent to have a CBCT scan performed. I understand that IF I require a copy to be taken out of this office, I am responsible to pay a $200 duplication fee. This fee is for the duplication of the CBCT only. This is not associated with any fee that you may incur with the maxillofacial radiologist or any other offices. You will be responsible for any fees incurred by the other office(s).

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed the notice before signing this consent.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with the restrictions, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
• The practice has the right to revoke the consent in writing at any time and all further disclosure will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

If YES, please list members allowed and relationship:

Dr. Beck periodically uses our patients’ images outside of the office for educating other patients, doctors, and dental professionals. We also may use images for marketing purposes as well as on social media. The following information will be used:

• My picture: including photographic, motion picture, and electronic (video) images.
• My voice: including sound and video recordings.

This consent grants Tareq Beck, DDS, MS and his subsidiaries, licensees, successors, and assigns, the right to use, publish and reproduce, for all purposes, my name, pictures of me in film or electronic (video) form, sound and video recordings of my voice, and printed and electronic copy of the information described in sections above in any and all media including, without limitation, cable and broadcast television and the internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences and in brochures and other print media. This permission extends to all languages, media, formats, and markets now known or hereafter devised. This permission shall continue forever unless I revoke the permission in writing.

Further, this consent grants Tareq Beck, DDS, MS and his subsidiaries all right, title, and interest that I may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant Tareq Beck, DDS, MS the right to give, sell, transfer and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit. I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment for Dr. Beck’s use of any of the material described above for any of the purposes authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer-generated scanned images and other electronic media that may be used in conjunction therewith or to approve the eventual use that it might be applied. I acknowledge that I have read the foregoing and I fully understand the contents.