CALL: (719) 576-5566

Oral Cancer Screening Consent Form

One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more that 25% of oral cancer victims have no such lifestyle risk factors. Studies also suggest that human papillomavirus (HPV) plays a roll in more that 20% of oral cancers causes. Oral cancer risk by patient profile as follows:

Increased Risk

Patients ages 18 – 39
Sexually active patients

High Risk

Patients 40 and older
Tobacco users: ages 18-39, any type within 10 years

Highest Risk Patients 40 and older w/ lifestyle risk factors (tobacco and/or alcohol use)
Previous history of oral cancer

Broadmoor Dental has incorporated VELscope into our oral screening standard of care. VELscope, in conjunction with a standard oral cancer examination, significantly improves the ability to identify suspicious areas at their earliest stages. VELscope powered by Sapphire, along with the doctor’s visual examination, is similar to proven early detection procedures for other cancers such as mamography, and gives the best chance to find any abnormalities at the earliest possible stage. As with all cancer early detection can minimize or eliminate potentially disfiguring effects and possibly save your life.

The VELscope powered by Sapphire examination will be offered to you annually. This enhanced examination is recognized by the American Dental Association, however it is not recognized by most insurance companies.

The fee for this enhanced examination is $25.00 and is due on the date of service.

Yes. Along with my standard oral cancer screening, I would prefer to have the VELscope enhanced examina tion at this time. No. I would prefer not to have the VELscope enhanced examination at this time and prefer the standard oral cancer screening alone.


Previous page: Patient Financial Policy
Next page: HIPPA Privacy Form