Please fill in the form details or click on the button below to download our CBCT Imaging referral form
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Please complete the following details:
Possibility Of Pregnacy?YesNo
To comply with the IR(ME)R 2000 regulations, all radiographs and CBCT scans are required to be justified, reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We are unable to provide a report for your requested radiographs and CBCT images unless you request one. We strongly recommend that all CBCT and other radiographic examinations are reported upon to rule out the possibility of coincidental pathology, and can arrange to provide a report for your requested images for an additional fee of £85 per image.
Please indicate which of the following two options is preferable:
You would like us to arrange for this patient’s radiographic examination(s) to be reported upon (£89 per image) (This report will be sent to you separately)
You are adequately trained and competent to interpret and report your own CBCT images.
Upper Right
18
17
16
15
14
13
12
11
Upper Left
21
22
23
24
25
26
27
28
Lower Right
48
47
46
45
44
43
42
41
Lower Left
31
32
33
34
35
36
37
38
Does the patient have a radiographic template?YesNo
Area Of InterestMaxillaMandibleBoth jaws
ImplantsOrthodonticsPathologyEndodonticsOral SurgeryBone GraftTMJSinus Lift
What type of image do you require?
2D Digital Panoramic
Yes
3D CBCT Imaging5cm x 5cm (1-4 teeth)8cm x 8cm (Both Jaws)5cm x 10cm (Single Jaw)10cm x 10cm (Both Jaws)
TMJ ViewsLeftRightBoth
Image FormatEmailCD
PaymentReferring Dentist
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