CT Scan Referral Form

PATIENT DETAILS

Title

Initials

Name

First Name Last Name

DOB

Prefered Contact Method

Address

Home Tel

Work Tel

Mobile Tel

Notes

REFERRING DENTIST DETAILS

Dentist Name

Dentist Email

Practice Name

Practice Address

Practice Tel No

Dentist Signature

GDC Number

Reason for Scan and Justification

CT SCAN REQUIREMENTS:

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque markers to be worn? Yes/No

CT SCAN CHARGES:

CBCT with Radiologist Report – £190.00

CBCT without Radiologist Report – £170.00

TOTAL

DISCLAIMER: Under the Referral Scan Request Terms the dental CBCT images will be reported on by the REFERRING PRACTICE. The referring practice will then be responsible for ensuring that the clinical evaluation takes place, is properly recorded and the patient fully informed.

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CT Scan Referral Form