CT Scan Request

Dental Referral

    Patient Details

    Patient Title (Required)

    Patient Surname (Required)

    Patient Forename(s) (Required)

    Address

    Postcode

    Date of Birth

    Telephone (Required)

    Email (Required)

    Possibility of Pregnancy

    Examination Required (Required)

    All images will be taken parallel to the occlusal plane unless you specify a different orientation below:

    It is an IR(ME)R requirement that the Referrer provides sufficient clinical information for the x-ray procedure to be justified. Please provide a brief clinical history and state the questions that the OPG or CBCT examination is designed to answer:

    Patient to wear stent provided by dentist:

    All CBCT's will be sent with Invivo Dental Viewer and DICOM images put onto a disc clearly labelled with the patients name and area scanned.

    It is an IR(ME)R requirement that the images must be clinically evaluated and the findings recorded in the patient's notes. Please state who will be doing this:

    Dentist Information

    Referring practice (Required)

    Dentist name (Required)

    Address

    Postcode

    Telephone number (Required)

    Email (Required)

    Accept Privacy Policy:
    Yes

    Alternatively you can download the offline version of the CT Scan Request form by clicking here 

    Click here if you would like to make a dental referral