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:

    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:

    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

    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