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:

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:
NoYes

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: