CT Scan Request

Dental Referral

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Patient Details

Patient Name
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 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 (required):

Referrer Details

GDPR Consent

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