IKON Dental - Patient Referral Form

Secure Patient Referral Form

Please complete the form below to refer your patient for specialist care at Ikon Dental. Upon completion of the specified treatment, we will pass your patients back to you for their continued dental care. Please be assured that we will keep you informed throughout your patient’s journey with us. Please contact the practice at any time should you have any questions or queries.
IS YOUR REFERRAL FOR A CBCT OR OPG? PLEASE COMPLETE THIS SECTION FIRST TO ONLY VIEW RELEVANT FIELDS ON THE FORM*

YESNO, something else
Dentist's Name OR Name of IRMER Practitioner if referring for CBCT/OPG*

First NameLast Name
Dentist's/ IRMER Practitioner's Email*
Dentist's/ IRMER Practitioner's Phone Number*
Practice Name and Address*

Practice Name

Street Address Line 1

Address Line 2City

Postcode
Patient's Name*

First NameLast Name
Patient's Email*
Patient's Phone Number*
Patient Address & Postcode*

Street Address Line 1

Street Address Line 2

CityCounty

Postcode
Patient's Date of Birth*

MonthDayYear
Date
Select the type of referral*

ImplantsRestorative DentistryEndodonticsOrthodonticsOral Surgery / ExtractionsPeriodontics
Reason for referral/patient's complaint
Relevant Medical History
Attach any relevant files or X-rays

Cancelof
Please tick an option-The cost of the CBCT/OPG will be directly charged to the patient

CBCT 3D scan without report £135 (single or double jaw)CBCT 3D Scan with report £260 (single or double jaw)OPG without report £75 (single or double jaw)OPG with report £145 (single or double jaw)
NOTE

Please note the results of the CBCT scan will not be medically evaluated by the IKON Dental Specialists Team (unless the report has been requested which an external provider will carry out). You, the referrer, will be required to do this and to treat your findings accordingly. Raw DICOM scanning data will be returned to you via a digital link. A CD with basic viewing software, which will produce a 3D image can be provided on request.
Clinical context for requesting the above examination *
Relevant results of history, clinical examination and other imaging *
What information do you want the radiographic examination to provide?*
Define the anatomical area that the radiograph should cover*
Have you AS A PRACTICE completed a Service Level Agreement Form before for CBCT/OPG? This is required to be completed ONCE for this and any future referrals for CBCT/OPFG.*

YESNO
If you have not completed a Service Level Agreement for CBCT/OPG before, this must be completed ONCE for this referral and future referrals.

Please click here to complete: https://form.jotform.com/242203890456052
Signature
Should be Empty:

Secure Patient Referral Form

NOTE