CBCT / OPG Imaging Referral Form

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PATIENT DETAILS

Patient Name *

Prefix

First Name

Last Name

Patient Date of Birth

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Patient Address

Address Line 1

Address Line 2

City

Postcode

Country

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Patient Contact Details

Phone Number

Email Address

Possibility of Pregnancy

Yes

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Relevant Medical History

Reason for referral and clinical justification for CBCT scan?

What information do you want the dental CBCT examination to provide?

Patient to wear stent provided by dentist?

Yes

OPG X-ray or Sectional 3D Scan (CBCT)?

Justification for radiograph

Define the scan volume required

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REFERRING DENTIST’S DETAILS

Referring Practitioner *

Prefix

First Name

Last Name

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Practitioner Address

Address Line 1

Address Line 2

City

Postcode

Country

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Practitioner Contact Details

Phone Number

Email Address

Have you completed Level 1 CBCT Training?*

Have you completed Level 2 Reporting CBCT Training? (If not an additional fee will be charged for the CBCT to be reported externally by us)

Do you require a report?

PAYMENT

Patient to Pay

Account to referrer

Opt-In

I confirm that my practice as signed the radiology referral SLA.

Opt-In

I confirm I have filled out all sections of the form

Please Note:

Patients are generally given the image data to take away with them on the day – both the DICOM File and Viewing Software and/or the Raw DICOM data (to be imported into your own CBCT Viewing software)

Patients will be returned to your care for all ongoing and routine dental treatment. Any follow-up appointments at our practice will relate solely to the treatment for which they were referred. We do not accept referred patients for general or routine dental care.

Important information: it is essential that you complete all sections of this form in full.

All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment.

The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

CBCT / OPG Imaging Referral Form

CBCT / OPG Imaging Referral Form

Please Note:

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Get in Touch!

enquiries@thewhitehouse.dental

01883 742 549