External Referral for CBCT / OPG

We offer a service providing CBCT or OPG scans.

The process:

1. The treating dentist must have minimum of level 1 CBCT in place, we will require evidence of this as it is a legal requirement. We will set up a service user agreement with the individual dentist. (If there are multiple dentists at a single practice we will require each dentist to register).

2. Submit this form. If it is a link and the form is completed online it will submit automatically. If you have downloaded a PDF or printed it then you will require to submit via email to the practice manager.

3. Once the aubmission is recieved we will contact the patient to arrange an appointment. We request payment ahead of the apppointment via a payment link.

For any quieries regarding this process or service agreements the practice manager can be reached on a.turner@eilertsen-dental.co.uk

Patient's Name*

First NameLast Name

Patient's DOB*

Date

Patient's Preferred Contact Phone Number*

Area CodePhone Number

Patient's Email Address *

example@example.com

OPG Requested*

Justifcation for referral *

CBCT Requested*

Justification for referral *

Do you wish us to request a report from JM Radiology

YesNo, I will report my own scan and have obtained CBCT level 2 (certificate has been sent)

The costs for reporting are as follows:
Dento-Alveolar CBCT (Up to 5x5) £125.00
Dento-Alveolar CBCT (Up to 8x5) £145.00
Dento-Alveolar CBCT (Up to 8x8) £165.00
Cranio Facial CBCT (Larger than 8x8) £185.00

OPG - Panoramic Radiograph £90.00
Periapical Radiograph £45.00
Bitewing Radiograph £45.00

Additional Services
ID canal marking Left Side £100.00
ID canal marking Right Side £100.00
Measurements Left Side Lower £100.00
Measurements Right Side Lower £100.00
Measurements Left Side Upper £100.00
Measurements Right Side Upper £100.00

We appreciate that there will be times that you need a report back sooner because of logistical issues. To support you we can offer an expedited turnaround time for a report, from time of submission. There is 100% surcharge of the report fee.

If requesting a report in addition to the scan Eilertsen Dental Care will request from https://www.jm-radiology.co.uk Please note reports can take up to 14 days from date of request.

If you would prefer the CBCT to be reported by an alternative provider (other than yourself or JM Radiology) please contact us.

Date of request for scan*

Date

Scan required by*

Date

Clinician's Name*

Practice Phone Number

Area CodePhone Number

Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Clinician Return Email *

example@example.com

User Service Level Agreement in Place*

AgreedRequired

Minimum level 1 CBCT achieved*

I have sent Certificate (first time using form)Agreed

I confirm I have advised my patient that the cost of the scan will be £150 (excludes report)

YesNo

Signature

EXTERNAL CBCT / OPG Referral Form