Practice Name
Referring Dentist
First Name
Last Name
Practice Email
example@example.com
Practice Postcode
Practice Telephone Number
Date Referred
-
Day
-
Month
Year
Date
Patient Name
First Name
Last Name
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Date of Birth
-
Day
-
Month
Year
Date
Patient Contact Number
Patient Email
example@example.com
Relevant Medical History
Reason For Referral
Endodontics
Implants
Restorative
CBCT
OPG
Endodontics
Diagnostic and Treatment planning
RCT
Re-RCT
Apical Surgery
Post Removal
Radiography upload
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OPG/CBCT
OPG
CBCT
Lateral Ceph
Reason for Scan
Implants
Orthodontic
Endodontic
Other
Area of interest
Sinus Exam
Dual Jaw
Mandible
Maxilla
Small Field 5x5
Full OPG
Reporting
To comply with IRMER 2000 regulations radiograph and CBCT scans should be reviewed by the referring practitioner or by a radiologist.This can rule out the possibility of pathology. We recommend a report via a consultant Radiologist.
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