Falsafi Ortho | Informed Consent Form

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

INFORMED CONSENT
CONE BEAM CT SCAN

1. A CBCT scan, also known as Cone Beam Computerized Tomography, is an x-ray technique that produces 3D images of your skull that allows visualization of internal bony structures in cross section rather than as overlapping images typically produced by conventional x-ray exams. CBCT scans are primarily used to visualize bony structures, such as teeth and your jaws, not soft tissue such as your tongue or gums.

2. Advantages of a CBCT Scan over conventional x-rays: CBCT 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. Benefits of CBCT scans include: A. Higher accuracy when planning implant placement surgery; B. Greater chance for diagnosing conditions such as vertical root fractures that can be missed on conventional x-ray films; C. Greater chance of providing images and information which may result in the patient avoiding unnecessary dental treatment; D. Better diagnosis of third molar (wisdom teeth) positioning in proximity to vital structures such as nerves and blood vessels prior to removal; E. The CBCT scan enhances your dentist’s ability to see what needs to be done before treatment is started.

3.Radiation: CBCT scans, like conventional x-rays, expose you to radiation. At the office of Dr. Falsafi , the dose of radiation used for CBCT examinations is carefully controlled to ensure the smallest possible amount is u sed that will still give a useful result. However, all radiation exposure is linked with a slightly higher risk of developing cancer

4. Pregnancy: : Women who are pregnant should not undergo a CBCT scan due to the potential danger to the fetus. Please tell the dentist if you are pregnant or planning to become pregnant.

5. Diagnosis of non-dental conditions: While parts of your anatomy beyond your mouth and jaw may be evident from the scan, your dentist may not be qualified to diagnose conditions that may be present in those areas. If any abnormalities, asymmetries, or common pathologic conditions are noted upon the CBCT scan, it may become necessary to send the scan to an Oral and Maxillofacial Radiologist for further diagnosis. If this occurs, we will discuss this option with you as well as the fee for the additional diagnosis and referral.

PLEASE DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT, AND AGREE TO ACCEPT THE RISKS AND ADVANTAGES NOTED.

, being 18 years or older, certify that I have read the above statement. I

understand the procedure to be used and its benefits, risks, and alternatives. I acknowledge that I have had a full opportunity to discuss the matter with Dr. Falsafi. I have been given the opportunity to have my questions answered, and accept the risks of the CBCT scanning procedure as described above, I therefore give my consent to have Dr. Falsafi and her staff as she may designate, perform a CBCT scan.

Signature of Patient, or Legal Guardian

Date:

Rebecca Falsafi, D.D.S., M.S. P.C.
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

i-CAT® CBCT INFORMED CONSENT

As of 2.26.10

About i-CAT® CBCT Cone Beam Scans

The office of Dr. Rebecca Falsafi now offers an exciting new technology for our patients and for patients of other doctors who might be referred here. This technology is i-CAT® Cone Beam Computer Assembled Tomography (CBCT) imaging, sometimes called 3-D radiographs or x-rays. Using CBCT means that we now have the ability to take 3-D images of the teeth, jaws, bones and facial structures at lower costs and with less energy than a typical CT scan used in hospitals. 3-D imaging provides improved diagnosis for our patients, especially in cases of impacted teeth, dental implants, surgical treatment, and even more complex cases. Understandably, you may have questions about exposure to these types of x-rays. Here are some facts you should know about 3-D imaging. The 8.5 second i-CAT® CBCT exposure is:

About ½ as much as a full series of orthodontic digital images
About 1/5 as much as a full mouth series of standard dental x-rays (28 films)
About 1/70 as much as a typical medical CT scan

CBCT offers our patients enhanced diagnostic value at significantly reduced exposure. Simultaneously, CBCT scans can image the entire head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws and the surrounding bone using CBCT’s for those limited purposes. Our training and dental license does not provide for evaluation and diagnosis outside those areas. Since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist who is trained and licensed to evaluate and diagnose a broader area. A CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The cost is $125.00. If you are interested in taking advantage of this service, please initial the applicable section and sign the acknowledgement below.

Yes, I want to have my i-CAT® CBCT scans read by an oral radiologist. I understand that I am responsible for this additional cost.

No. I understand the risks and benefits of having my CBCT read and interpreted by an oral radiologist However, I am knowingly declining such a referral.

Print Patient Name

Signature of Responsible Party

Date:

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

HIPAA/Record Release Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. Your name and signature on this form indicate that you have been given the opportunity to review and request a copy of Rebecca Falsafi, D.D.S., M.S.' Notice of Privacy Practices. If you have any questions regarding the Privacy Practices, please do not hesitate to contact the office and speak with the Patient Privacy Officer.

The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. You have the right to restrict how your protected health information is used and disclosed.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations and potentially anonymous usage in a publication.
The practice reserves the right to change the privacy policy as allowed by law.
The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

May we use phone, email, and text for communication and confirmations?

YES NO

May we leave messages on your home or cell phone answering machine?

YES NO

May we discuss your treatment and/or finances with any additional person(s)?

YES NO

If YES, please list their names, relationship and restrictions, if any:

I hereby release Rebecca Falsafi D.D.S, M.S. and staff from any legal responsibility or liability for the disclosure of any protected health information as authorized on this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.

Print Patient's Name:

Signature of Patient (or Patient Representative)

Date:

Printed Name of Patient or Patient Representative

Relationship to Patient

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

OFFICE POLICY REGARDING INSURANCE

We understand that orthodontic insurance can be a complicated endeavor; we will try our best to make understanding your specific insurance plan as simple as possible. Please review the following facts regarding orthodontic insurance:

Orthodontic insurance coverage is different from general dental insurance.
Orthodontic insurance has a one-time lifetime maximum. This is separate from the annual maximum used for general dental visits.
The amount of your orthodontic coverage is determined by you (your employer) and your insurance company. Our office does not negotiate the terms of your coverage.
Normally insurance companies only cover a percentage of your orthodontic fee up a maximum amount. The balance of your fee (co-pay) is your responsibility. We will do our best to make payment arrangements that fit your budget.
Some insurance companies will only pay you. In this case we will be happy to work with you in filing the forms and explaining the terms of your coverage so you receive the maximum benefits from your policy.
It is your responsibility to provide our office with all insurance information and completed insurance forms. We will accept your insurance, only if all information is correct and provided by you. Otherwise we can have them send the checks to you.
If you have any changes to your insurance policy you are responsible to notify us as soon as possible of these changes.
As per the Federal Truth and Lending if new and/or additional insurance is acquired during treatment any and all discounts will be evaluated and treatment fee may be adjusted.

It is a courtesy to our patients that we accept payment directly from your insurance company, but the financial responsibility still remains with the parent/patient. If for any reason your insurance company does not make payment as anticipated you are responsible to complete your fee to us. It is our office policy, as is most orthodontic offices; that braces are not removed until payment is made in full. If at any time you have any questions and/or concerns regarding your insurance please call the office we and will be happy to assist you.

Patient Name

I have read and understand the above information

Rebecca Falsafi DDS, MS 3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10 East Amherst, NY 14051 www.falsafiortho.com

INFORMED CONSENT CONE BEAM CT SCAN

Rebecca Falsafi, D.D.S., M.S. P.C. 3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10 East Amherst, NY 14051 www.falsafiortho.com

i-CAT® CBCT INFORMED CONSENT

As of 2.26.10

About i-CAT® CBCT Cone Beam Scans

Rebecca Falsafi DDS, MS 3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10 East Amherst, NY 14051 www.falsafiortho.com

HIPAA/Record Release Consent Form

Rebecca Falsafi DDS, MS 3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10 East Amherst, NY 14051 www.falsafiortho.com

OFFICE POLICY REGARDING INSURANCE

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

INFORMED CONSENT
CONE BEAM CT SCAN

Rebecca Falsafi, D.D.S., M.S. P.C.
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com