Dentists - CBCT Referral Form

Referring Dentist Details

Referring Dentist

Practice Name

Practice Address 1

Practice Address 2

Practice Address 3

Practice Postcode

Practice Telephone

Practice Email

Reason for Scan

Implants

Ortho

Impacted Teeth

Endodontics

Sinus Exam

Patient Details

Patient Name

Telephone

Mobile

Email

Date of Birth

Relevant Medical History

Area of Interest

Dual Jaw

Mandible

Maxilla

Small Field 5x5

True 2D OPG

Area of Interest (please enter numbers separated by commas)

Special Instructions

Reporting

To comply with IRMER 2000 regulations radiographs and CT scans should be reviewed by the referring practitioner or by a radiologist. This rule can rule out the possibility of coincidental pathology. We recommend this service and are happy to offer a report via a Consultant Radiologist.

By not ticking this box I am happy to make my own arrangements.

Reporting (Tick if Yes)

Practitioner Name

Signature

I agree with all terms and conditions

Date

13/02/2025