CBCT Scan Referral Form

CBT Scan Request Form

Step 1. Patient Details

Step 2 - Referring Dentist's Details

Confirmation of Irmer Referrer Training* YesNo

I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party of Dental Cone Beam CT Equipment. (Click to read guidance notes)

Step 3 - Scan Details / Region of Interest

Region to be scanned Small Volume (sectional Scan 4-5 teeth)MandibleZygomasMaxillaeBoth Patient to wear stent provided by dentist?* Please Select *YesNo

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.

Reason for Referral and Justification for the scan*

Special Instructions to IRMER operator involved in scan acquisition*

Step 4 - Costs

Please select services required* Standard CT Scan (includes free viewing software or email) (Suitable for Nobelguide if you have the Nobelguide software) Dental CBCT Scan : £185

DeliveryCBCT will be sent via email

File Attachments Please include any relevant file attachments such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.

Any Additional Comments

Reporting of Scans I fully understand and accept that The Row does not report on the scans and radiographs requested by referring GDPs I am the IR(ME)R referrer/operator I am adequately trained to report on my patients scan

Dentist Declaration I confirm that I fully understand that to comply with IR(ME)R regulations all scans must be reviewed and reported into the patient's clinical records by myself the referring GDP