Cavitat Consent

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Cavitat Consent

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Cavitat Scan Consent

Cavitat Scan: Patient Consent and Understanding
Full Name*
First Name Last Name
I hereby give my permission for Dr. Wall to perform an ultrasonic scan of my jawbone using the CAVITAT. I understand that this scan, which is being done at my request, has been approved by the FDA for the identification of areas of jawbone experiencing compromised bone density. I understand that the only way to diagnose "cavitations" with 100% certainty is to perform a biopsy of the likely areas of diseased jawbone tissue and have a lab test/analyze the tissue samples for necrotic material. I further understand that the CAVITAT poses absolutely no health risk, nor should it produce any discomfort when used to scan my jawbone. Potential benefits of the CAVITAT include identification of jawbone cavitations, as well as obtaining of detailed information about them, which may aid in improving surgical treatment outcome. I understand that my patient records generated from this scan will be held in strictest confidence.
The cost for the above listed treatment is:
Patient, Parent/Guardian*
First Name Last Name
Doctor
First Name Last Name
Date
MM slash DD slash YYYY
Witness
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