Title
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Please Select
Mr.
Miss
Mrs
Ms
Dr.
Other
First Name(s)
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Last Name(s)
*
Address
*
Street Address
Street Address Line 2
City
Post Code
Date of Birth
*
Patient's Email Address
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Patient's Phone Number
*
Referral to:
Dr Ferhan Ahmed
Dr Tariq Bashir
Jennifer White
Type of Referral
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Urgent
IV Sedation
Surgical Dentistry
Implant(s)
OPT
CT Scan
Cosmetic Dentistry
Endodontics
Invisible Braces
Restorative Dentistry
Prosthodontics
Hygiene Services
Other
Reason for Referral
*
Justification for digital OPT or CT scan
OPT
Left Side
Right Side
Full mouth
CT Scan: Select Area of Interest
Maxilla
Mandible
Both
Small Section
Please Specify Required CT Scan Section / Teeth being replaced
CT Scan: Type & Size
Dual jaw mode (8 cm x 9 cm) - capture both dental arches in a single scan for cases that involve a larger area
Single jaw mode (8 cm x 5 cm) - ideal for cases that require a full view of either mandible or maxilla, including implant planning with surgical guide creation and oral surgeries
Universal field of view (5 cm x 5 cm) - the ideal compromise of image size and dose, this mode ensures you receive the details you need, with no unnecessary information; ideal for most local dental applications
EndoHD mode (5 cm x 5 cm; 75 µm resolution) - high-resolution mode delivers maximum precision for exams that require greater visibility of the patient’s root and/or canal morphologies; best-suited for endodontic applications
Pediatric program (4 cm x 4 cm) - limit patient exposure by confining radiation to a small area; a great option for younger patients, implant planning, and follow-up exams
CT Scan Declaration
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I declare that I have received training in CBCT referral and will use CBCT selection criteria, as per current UK guidelines.
CBCT Scan Reporting
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Please provide me with a Cone Beam CT scan report. I am aware that there is an additional charge of £75.00 for this and have informed my referred patient of the additional cost.
I will make my own arrangement for the reporting of my Cone Beam CT scans acquired at FAME Dentistry. This will be done by someone adequately trained as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT.
I will report my Cone Beam CT scans acquired at FAME Dentistry. I confirm that I am adequately trained to interpret Cone Beam CT scans as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. I will ensure that my training remains up to date.
Has a stent been made?
Yes
No
Confirm patient will bring stent at appointment
Yes
No
X-rays / Any other relevant files enclosed?
*
Yes
No
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Has the patient been referred before?
*
Yes
No
Is the patient pregnant?
*
Yes
No
Any relevant medical history?
*
Yes
No
Relevant Medical History
Practitioner Name
*
Referring Dentist GDC No
Clinic Name
*
Clinic Email Address
*
Clinician's Email Address
*
Clinician's Phone Number
*
Any Other Information
Signature
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