Home » Cone Beam CT (3D) Scan or OPT (2D) Scan Referrals

Cone Beam CT (3D) Scan or OPT (2D) Scan Referrals

At Evesham Dental Health Team we are very grateful and honoured to accept referrals from our professional friends and colleagues. We will always respect this privilege by taking our utmost care, provide the requested advice / treatment and following completion return patients to their own practice for ongoing dental care.

How to make a referral:

Submit online Please complete the following form and attach any photographs, radiographs or notes you wish to include in your referral. You will receive a copy of the form sent to the Practice Email address you have provided.
Click here to download a printable PDF version of the below form. Once filled in, please return to us via post.

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Practice Details

Referring Practice:
Referring Practitioner:
Practice Email:
Practice Address:
Practice Telephone:

Patient Details

Patient Name:
Date of Birth
Patient Email:
Patient Address:
Patient Telephone (Work):
Patient Telephone (Home):
Patient Telephone (Mobile):

History (Comments about this referral):

Scan Information

Type of Scan

Opt
Cone Beam CT Scan
Airway Analysis with SICAT Air

Patient to wear Radiographic Marker?

Scan Size (Indicate Area on Diagram Below)

Airway Analysis (11 x 10)
Mandible / Maxilla (8 x 8)
Sextant (5.5 x 5)

Upper Right
- 8
- 7
- 6
- 5
- 4
- 3
- 2
- 1
Upper Left
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
Lower Right
- 8
- 7
- 6
- 5
- 4
- 3
- 2
- 1
Lower Left
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8

Region of interest and justification for Scan (Mandatory):

Radiographs & Clinical Photographs

If you would like to attach any radiographs, clinical photographs or any documents that you feel would be of use, please use the upload facility below.

Upload 1:
Upload 2:
Upload 3:
Upload 4:

Your Preference:

Patient to pay £165 at scan appointment

or Invoice £165 to referring dentist

Patient to take image on Memory Stick

or send/post image to referring dentist

Fee of £165 includes scan DICOM file on disc and Pathology Report

FORMAT DATA DELIVERY FOR CT SCAN WILL BE BY CD IN POST

To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. All CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. All our CBCT scans are sent to a reporting service by a Consultant Radiologist. The resultant Pathology Report is emailed to you the referring dentist/doctor.

Thank you for your referral.

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