CBCT Referral Form

Please complete the form below and we will contact the patient as soon as possible:

Referring Dentist Details*

Referring Dentist*

Practice Name*

Practice Address 1*

Practice Address 2*

Practice Postcode*

Practice Phone Number*

Practice Email*

Patient Details*

Relevant Medical History*

Reporting*

IRMER 2017 Regulations: We do not routinely report upon referred 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 strongly recommend that all CT and other radiographic examinations should be reported upon to rule out the possibility of co-incidental pathology.

By not ticking this box, I confirm I will make my own reporting arrangements.

Reporting (Tick if Yes)