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CBCT Referral Form

Click here to download/print a referral form

DIGITAL PANORAMIC REFERRAL DETAILS

With TMJWithout TMJ

CBCT EXAMINATION REFERRAL DETAILS

Small volume (please indicate, If no teeth are selected, the whole jaw will be scanned)
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PATIENT DETAILS

Title First Last Suffix

Street Address *
Address Line 2
Postal / Zip Code *
City
Country
Possibility of pregnancy *

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MEDICAL HISTORY


Radiographs available *

REFERRING DENTIST'S DETAILS

First Last

Street Address
Address Line 2
Postal / Zip Code
City
Country



PURPOSE & PROPOSED COURSE OF TREATMENT



Patient to payAccount to referrer

IRMER 2000 Regulations: We do not routinely report on scans or radiographs. To comply with the IRMER 2000 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We can arrange for a report to be prepared by a Consultant Radiologist if this is requested by you.