CBCT Referral Form Title Dr Mr Master Mrs Miss Ms Other Gender Male Female Date Of Birth Foreame(s) Surname Address Line 1 Address Line 2 Town or City County Postcode Email Phone Number Medical Declaration Tick box to indicate there is no contra indication to this patient receiving a Cone Beam CT Scan. Disabilities Purpose Of Scan Stent Required yes no Stent Ready Date, if stent required Radiographic Stent Tick box to indicate Fit of stents has been checked by prescribing dentist for accuracy and stability prior to scan or where no stent is required. Bridge Street Dental have no liability for the production or provision of the stent. Guided Surgery Please tick this is you require a full jaw. Please Choose Scan Type CBCT Dual Jaws [8x9] CBCT Dual Jaws [12x10] CBCT Single Jaw [8x5] CBCT Single Jaw [12x5] Sectional [5x5] OPT Sectional OPT Full Area to be scanned Justification for area requested Special Instructions Patient Fit Tick box to declare the patient fit and the scan appropriate for dental assessment. Accept DSS Tick box to declare you have read and accept that DSS does not report upon scans and radiographs requested by referring GDP. To comply with IRR17 and IR(me)R17 regulations all radiographs and scans must be reviewed and reported into the clinical records by the referring GDP or radiologist. We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. Payment Details Payment to be made by patient Payment to be made by the referring GP Referring Dentist Forename Referring Dentist Surname Referring Dentist Practice Name Referring Dentist Phone Number Referring Dentist Email Send Referral Form
