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Sedation & imaging · CID-SED-03 · v1.0

3D CBCT Scan Consent

Consent for cone-beam computed tomography used in diagnosis and treatment planning.

About 5 minutesRead, sign and download from your own device

Completion

0%

0 of 16 required items

  • Patient details
  • Patient-specific fields
  • Acknowledgments
  • Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Treating dentist

Dr. Jain & Dr. Gupta

2. What you are agreeing to

Proposed imaging

Cone-beam computed tomography (CBCT) creates a three-dimensional view of teeth, jaws, sinuses, nerves, and related structures. The scan may be used to diagnose conditions and plan implant, surgical, endodontic, or other care.

Benefits and limitations

  • CBCT can show anatomy and pathology not visible on two-dimensional dental X-rays.
  • The scan is limited to the captured field and image quality. It does not guarantee that every condition will be identified and may require interpretation or referral.

Material risks and alternatives

  • CBCT uses ionizing radiation. The dose depends on the machine, field of view, and settings; unnecessary repeat imaging should be avoided.
  • Pregnancy or possible pregnancy must be disclosed before imaging.
  • Alternatives may include conventional dental radiographs, medical CT, MRI, ultrasound, clinical observation, referral, or no imaging, depending on the diagnostic question.
  • Declining recommended imaging can limit diagnosis or treatment planning and may mean treatment cannot proceed safely.

3. Your case, in your words

Are you pregnant or is there a possibility you may be pregnant?

4. Confirm, then sign

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Who is responsible for this document

Responsible clinicians

  • Dr. Sambhav (Sam) Jain, DMD, MS

    Lead Implant Dentist & Founder · CA Dental License #50472

  • Dr. Arpana Gupta, DDS, MDS

    Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

  • Fremont

    3381 Walnut Ave, Fremont, CA 94538
    Phone (510) 574-0496 · Fax (510) 574-0499

  • San Francisco

    4318 Geary Blvd, Suite 201, San Francisco, CA 94118
    Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-SED-03 · v1.0 · Effective 31 Jul 2026 · Next clinical review 31 Jul 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS