CT-Scan Referral Form Please fill in the form below to provide information about the CT Scan Referral. First Name Last Name Email Telephone Date of Birth Patient Address Name of Dentist Dentist’s Phone Number Practice Postcode Referring Dentist Email Address Referrer GDC Number Practice Address Confirm Irmer Referrer Training * Confirm Irmer Referrer Training * Yes Region to be Scanned * Region to be Scanned Maxillae Mandible Both Other Patient to wear stent provided by dentist ? * Patient to wear stent provided by dentist ? * Yes No Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications. * Yes, patient is competent Yes, patient is competent 2nd scan, of stent, required ? * 2nd scan, of stent, required ? * Yes No Reason for Referral and Justification for the scan Special Instructions to IRMER operator involved in scan acquisition Confirm image only * Confirm image only * Yes No Radiologist report needed * Radiologist report needed Yes No Treatment Costs * Treatment Costs * Dental CT Scan for single tooth or jaw : £___ Dental CT Scan for both jaws : £___ Second scan of stent for “Nobelguide” or similar : £___ Radiologist report, where requested, shall be quoted separately. NOTE : CT-Scan files will be given to the patient on a CD with the required viewing software. Acceptance * I consent to my data being used in accordance to the Privacy Policy. I consent to my data being used in accordance to the Privacy Policy. Submit
