Stoke Dental
Complete this form to refer a patient for CBCT imaging at Stoke Dental. Please ensure all sections are filled accurately.
I confirm that the patient has been made fully aware of the access arrangements at Stoke Dental, including the requirement to ascend a flight of stairs to attend for CBCT imaging.
*
Yes
Dentist Name
*
First Name
Last Name
Practice Name
*
Practice Address
*
Practice Email
*
example@example.com
Practice Telephone / Mobile
*
Please enter a valid phone number.
Format: 00000 000000.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Patient Address
*
Patient Email
example@example.com
Patient Mobile
Please enter a valid phone number.
Format: 0000 000000.
Reason for Scan
*
Implant Planning
Endodontic Assessment
Other
Reason for Scan - Other (please specify)
Area(s) to be imaged (please specify tooth/region)
*
IR(ME)R Justification (clinical justification for CBCT exposure)
*
Patient has been informed of the CBCT cost (£150 payable at time of booking) and consents to proceed.
*
Yes
Patient understands the purpose and nature of CBCT imaging.
*
Yes
Transparent communication with patient – clarification of whether £150 CBCT fee is in addition to treatment costs
Additional Clinical Information (relevant medical history / previous radiographs)
Referring Dentist Signature
*
Referral Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Referring Dentist GDC No.
*
Submit Referral
Submit Referral
Should be Empty: