CBCT REFERRAL FORM
Using the Form Below
Referring Practice Name:
*
Name of Clinic
Referring Dentist Full Name:
*
Name of Dentist or Clinic
GDC Number
*
Name of Dentist or Clinic
Clinic's Email
example@example.com
Clinic Phone Number
*
Practice Address
*
Street Address
Street Address Line 2
City
County
Post Code
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PATIENT INFORMATION
Patient's Name
*
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Patient's Phone Number (Mobile)
*
Mobile
Patient's Phone Number (Home)
Home
Patient's Email
example@example.com
Patient's Address
*
Street Address
Street Address Line 2
City
County
Post Code
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Clinical Information
The clinical reasons for requesting a dental CBCT:
*
Choose the type of scan:
*
CBCT scan Only (£200)
CBCT Scan Plus Radiological Report (£250)
Any other anatomical area that the scan should cover:
*
What information do you want the dental CBCT examination to provide:
*
OTHER RELEVANT INFORMATION/BRIEF TREATMENT HISTORY:
How would you like to receive the scan?
*
Please securely Email me the raw DICOM files
Please hand a copy of the CD to the patient.
Please post me a copy of the scan on CD.
REPORTING OF SCANS:
*
I am the IRMER referrer only. I request that Woodbridge Hill Dental Practice provide me with a report on my patient's scan
I am the IRMER referrer/operator. I am adequately trained to report on my patient's scan
If a report is required, how would you like to receive the report?
*
Email
Letter
Please Attach X-rays, Images and Notes below. You can select and upload multiple files.
Radiographs
X-Ray (OPG)
Browse Files
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of
X-Ray (PA/BW)
Browse Files
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of
Submit
Print Form
Should be Empty: