CBCT Scan Request

CBCT Referral

Date of referral

Referrer Details

Referring dentist's name

GDC number

Practice name

Practice address

Address Line 1

Address Line 2

City

Post Code

Practice phone number

Practice email address

Referring dentist's mobile (optional)

Patient Details

Title

First Name

Last NName

Date of birth

Daytime phone

Mobile

Patient Email

Patient address

Address Line 1

Address Line 2

City

Post code

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.

Scan CBCT details / Region of interest

Digital OPT (requested with CBCT)

CBCT - Full Maxilla

CBCT - Full Mandible

CBCT - Full Maxilla and Mandible

CBCT - Small sectional field

Sectional requirements

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

Is the patient attending with a radiographic template?

Yes

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.

Clinical justification

Confirm shape of residual alveolus

Confirm descent of nasal / maxillary sinus prior to implant placement

Confirm position of mandibular canal / mental foramen prior to implant placement

Assess impacted teeth

Endodontic planning - please define primary area of interest

Additional justification / information

Special Instructions to IRMER operator involved in scan acquisition

Reporting

The requested CBCT scan is to be reported by referring clinician. Would you prefer the scan to be reported by a Consultant maxillofacial radiologist? (Additional fee of £85)*

Would you prefer the scan to be reported by a Consultant maxillofacial radiologist?

Yes

Payment

Who is responsible for payment?

Patient at appointment

Invoice referring practitioner

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

Via telephone

Via telephone & letter

Via telephone, letter & email

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

Yes

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 and by signing below I have, as a minimum, secured level 1 CBCT training and this training is in date. 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.

Referring dentist's signature

Mon	8:30 - 6:00pm
Tues	8:30 - 5:00pm
Wed	8:30 - 6:00pm
Thur	8:30 - 5:00pm
Fri	8:30 - 5:00pm

Referrer Details

Patient Details

Scan CBCT details / Region of interest

Clinical justification

Reporting

Payment

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