CBCT Referral Form

CBCT Referral Form

Download/print a referral form

DIGITAL PANORAMIC REFERRAL DETAILS

CBCT EXAMINATION REFERRAL DETAILS

Small volume (please indicate, If no teeth are selected, the whole jaw will be scanned)
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PATIENT DETAILS

Title First Name Last Name Suffix

Street Address *
Address Line 2
Postal / Zip Code *
City
Country
Possibility of pregnancy *

YesNo

MEDICAL HISTORY


Radiographs available *

REFERRING DENTIST'S DETAILS

First Name Last Name

Street Address
Address Line 2
Postal / Zip Code
City
Country

PURPOSE & PROPOSED COURSE OF TREATMENT

IRMER 2017 Regulations: We do not routinely report on scans or radiographs. To comply with the IRMER 2017 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We can arrange for a report to be prepared by a Consultant Radiologist if this is requested by you.

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