CT Scan Request

Patient Details

Patient Title (Required)
---MrMrsMsOther

Patient Surname (Required)

Patient Forename(s) (Required)

Address

Postcode

Date of Birth

Telephone (Required)

Email (Required)

Possibility of Pregnancy
NoYes

Examination Required (Required)
CT MaxillaCT MandibleBothOPG
All images will be taken parallel to the occlusal plane unless you specify a different orientation below:

The clinical content for requesting a dental CBCT:

Relevant results of history, examination and other imagining:

What information do you want the dental CBCT examination to provide:

Define the anatomical area that the scan(s) should cover:

Patient to wear stent provided by dentist:
NoYes

It is an IR(ME)R requirement that the reported images must be clinically evaluated and the findings recorded in the patient's notes. It is also required that the referrer is qualified and trained for this purpose. PLease confirm here by entering FULL NAME and GDC number below:

Referrer Details

Referring practice:

Full name (Required)

Address

Postcode

GDC Number:

Telephone number (Required)

Email (Required)

Accept Privacy Policy:
Yes