CBCT referral request

To refer a patient to Sharrow Vale Dental Care for a CBCT scan please complete and submit the following form.

Please include all relevant clinical information regarding this case.

We will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on their progress throughout. Please note, we do not provide reporting on the completed scans unless requested.

Patient details

Patient address

Date of Birth

Brief patient history and reason for referral

Relevant medical history. Please specify medications and allergies

Scan CBCT details / Region of interest

All scans will be parallel to the occlusal plane unless otherwise requested

If images are to support surgical or endodontic procedures please define primary area/s of interest

Is the patient attending with a radiographic template?

Clinical justification

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.

Special Instructions to IRMER operator involved in scan acquisition

Reporting

Payment

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Sharrow Vale Dental Care

I confirm that the patient has given consent to be contacted by Sharrow Vale Dental Care

This will act as the practitioner’s electronic signature: I hereby authorise Sharrow Vale Dental Care to carry out a CBCT on my behalf. The CBCT will be returned via email or on disc. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Sharrow Vale Dental Care and the Operator will not be responsible for assessing the CBCT for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of Radiology Training Courses is deemed a regulatory requirement for all users of radiographs, including those who are simply referring patients for acquisition of a CBCT. I accept that it is my responsibility to obtain the necessary qualification in order to refer and evaluate the data requested by me and provided by Sharrow Vale Dental Care. Alternatively, I will arrange for a Consultant Radiologist to rule out coincidental pathology unless requested previously on this form