CBCT Scan Referrals
Step 1 - Patient Details
Patient Name
*
First Name
Last Name
Patient Contact Number
*
Please enter a valid phone number.
Format: 0000 0000000.
D.O.B.
*
/
Day
/
Month
Year
Patient Email
*
Step 2 - Referring Dentist's Details
Dentist Name
*
Dentist Phone Number
*
Please enter a valid phone number.
Format: 0000 0000000.
Dentist Email
*
Dentist Address
*
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist GDC Number
*
Confirmation of Irmer Referrer Training
*
Yes
No
In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.
Step 3 - Scan Details / Region of Interest
Region to be scanned
Small Volume (sectional Scan 4-5 teeth)
Mandible
Zygomas
Maxillae
Both
Patient to wear stent provided by dentist?
*
Please Select
Yes
No
In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.
Reason for Referral and Justification for the scan
*
Special Instructions to IRMER operator involved in scan acquisition
*
Step 4 - Costs
Please select services required
Standard CT Scan (includes free viewing software or email) (Suitable for Nobelguide if you have the Nobelguide software)
*
Dental CBCT Scan : £160
Delivery - CBCT will be sent via email
File Attachments
Browse Files
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Choose a file
Please include any relevant file attachments such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF. Max. file size: 64 MB.
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of
Any Additional Comments
Reporting of Scans
*
Dentist Declaration
*
Submit
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