CBCT Referral Form

Your Practice Details (Please ensure this section is fully completed)

Practice Name: Practice Address: Practice Email: Telephone:

Patient Details

Title: Name: Address: Date of Birth: Postcode: Telephone (Day): Telephone (Eve): Mobile: Email:

Please indicate the 3D CBCT area of interest:

Both Jaws (£250): Mandible (£150): Maxilla (£150): Small Field of View - 5x5cm or 8x5cm (£150): Please stipulate the exact teeth/area you require e.g. "Upper left 3 - 6":

JUSTIFICATION FOR SCAN (IRMER 2000):

Implant treatment planning (assessment of position of anatomical structures, bone quality and quantity): Orthodontic assessment and planning: Impacted wisdom teeth assessment: Endodontic assessment: TMJ: Other (Please specify):

To be completed by the referring practitioner:

This will act as the practitioner’s electronic signature: I hereby authorize The Dental Practice to carry out a 3D CBCT on my behalf. When scanning guides are used, these guides will be prepared in advance by the referring dentist and given to the patient to bring to the scan appointment.

The results of the scan will be returned on disc with basic viewer software. Although an evaluation of the scan will be carried out and a report supplied, I am responsible for assessing the data and referring to the necessary specialties as clinically indicated.

The Dental Practice and the Operator will not be responsible for assessing the scan for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of a CBCT Training Certificate Course is deemed a regulatory requirement for all users of CBCT systems, including those who are simply referring patients for acquisition of a CBCT image. I accept that it is my responsibility to obtain the necessary qualification in order to refer and evaluate the data requested by me and provided by The Dental Practice. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.

Referring Practitioner: GDC Reg No: Additional Comments: