Please check if the patient has any of the following conditions either now or in the past. The answers you provide are for office records only and will be considered confidential.
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene; are there any restrictions, handicaps, or problems that might be encountered during treatment?
I understand the information I have given is true and correct to the best of my knowledge, it will be held at the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.
I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in this form.
I understand Credit Bureau information may be obtained for office payment plans.
I agree that the dental practice may communicate with me electronically at the email address below.
I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
I am responsible for providing the dental practice any updates to my email address.
I can withdraw my consent to electronic communications by calling: 954-452-9988 OR firstname.lastname@example.org
Acknowledgement of Receipt of Notice of Privacy Practices
* You May Refuse To Sign This Acknowledgement *
I have received a copy of this office's Notice of Privacy Practices.
Jacaranda Orthodontics and Pediatric Dentistry now offers an exciting new technology for our patients and for patients
of other doctors who might be referred here. This technology is called I-Cat Cone Beam Computer Assembled
Tomography (CBCT) imaging, sometimes called 3-D radiographs or x-rays. Using CBCT means we now have the ability to
take 3D images of the teeth, jaws, bones and facial structures at lower costs and with less energy than a typical CT scan
used in hospitals. 3D imaging provides us the opportunity of improved diagnosis for our patients, especially in cases of
impacted teeth, dental implants, surgical treatment, as well as 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.
An ICAT CBCT exposure is:
- About 1/2 as much as a full series of x-rays
- About 1/5 as much as a full (28) mouth series of standard dental x-rays
- About 1/70 as much as a typical medical CT scan
CBCT therefore offers our patients enhanced diagnostic value at a significantly reduced exposure. At the same time,
CBCT scans can image the entire head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws and
surrounding supporting bone, using CBCT’s for those limited purposes.
Our training and dental license does not provide for evaluating and diagnosing outside those areas. However 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, trained and licensed to evaluate and diagnose a broader area. 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 average cost is about $
$195.00. If you are interested in taking advantage of this service please initial the application section and sign the