CBCT Referral Form

Kindly fill out the form to refer a patient for our services.

We are currently not taking CBCT or OPT referrals.

Thank you for showing interest regarding the referral.

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Patient's Details

Referring Dentist's Details

Confirmation of IRMER referring training *
Confirmation of IRMER referring training
Digital Panoramic Referral Details (OPT) *
Digital Panoramic Referral Details (OPT)
Areas to be scanned for CBCT *
Areas to be scanned for CBCT
Declaration *
Declaration
Please select from the following options *
Please select from the following options
Reporting of Scans *
Reporting of Scans
Declaration of the referring dentist *
Declaration of the referring dentist
Signature *
Clear Signature
(Sign above after checking the box in the declaration to acknowledge the inclusion of all data required for us to proceed)

IRMER 2017 Regulations: We do not routinely report upon referred scans or radiographs. To comply with the IRMER 2017 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We strongly recommend that all CT and other radiographic examinations should be reported upon to rule out the possibility of co incidental pathology.

CBCT scan will be sent via the email provided. Please do not hesitate to contact the practice, if need be. Thank you for the referral.