First Name:
Middle Initial:
Last Name:
I hereby consent to Rankin & Fiume Orthodontics performing radiologic services as ordered and recommended by my dentist
Name of Dentist
The radiologic service provided is a CBCT (Cone Beam Computer Assembled Tomography) Scan. This x-ray technology allows for 3D radiographic imaging of the teeth, jaws, bones and facial structures at lower costs and significantly less energy than a typical CT scan used in hospitals. This type of imaging allows dentists the opportunity of improved diagnosis and treatment planning for our patients, especially in cases of impacted teeth, dental implants, endodontic treatment, oral pathology, surgical treatment and more complex cases. The fee for this radiologic service is $200.00.

The risks of submitting to CBCT Imaging, has been fully explained to me by my dentist. I have discussed the need for these radiologic services with my dentist, and agree to undergo the radiologic services recommended by my dentist. I understand Rankin & Fiume Orthodontics has made no recommendations regarding the need for theses radiologic services or the type of radiologic services to be performed.

I understand that Rankin & Fiume Orthodontics will provide no professional interpretation of the radiologic images obtained on the order and recommendation of my dentist. I further understand that Rankin & Fiume Orthodontics will provide no treatment and will make no recommendations for my treatment based on these radiologic studies to either me or to my dentist. I understand that Rankin & Fiume Orthodontics is only providing a technical service to my dentist by allowing my dentist to utilize the radiologic equipment operated by Rankin & Fiume Orthodontics. I hereby authorize Rankin & Fiume Orthodontics to provide my radiologic studies and related information to my dentist for his/her sole professional interpretation
As dentists, we evaluate teeth, jaws and surrounding/supporting bone using CBCTs for those limited purposes. Our training and dental license does not provide for evaluating and diagnosing outside those areas. 3D Imaging commonly reveals sinus, tonsil, adenoid, airway issues and other areas. Since CBCT imaging can cover a broader area, Rankin & Fiume Orthodontics would like 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. The fee for this service is an additional $150.00. If you are interested in taking advantage of this additional service, please select the applicable section below.
By signing below, I consent to having my CBCT Scan taken at Rankin and Fiume Orthodontics.
Name of Patient:
If under 18, Print Name of Parent/Guardian/Responsible Party:
Signature of Patient (or Signature of Parent/Guardian if under 18):