3D CBCT Scan Referral Form
Please fill in the following form to refer a patient to our practice for a CBCT scan. You as the referrer will be kept updated on the patient's progress and will receive a discharge form and the 3D CT Scan in your chosen format.
You will be emailed a copy of this form instantly and the patient will be contacted and booked in as soon as possible.
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What's the Patient's full name? *

 
What is {{answer_13355479}}'s Address please?

 
What is the patient's Date Of Birth?

 
What is the patient's Mobile (or Home) Number?

Please add as many numbers as you wish!
 
Any relevant medical history?

 
Is there a possibility the patient is pregnant?

     
 
What area are you referring the patient for a scan of? *


 
What is your justification for taking the CBCT Scan?

e.g. Implants, Complex Endodontics, Lesions and anatomical assessment, Third Molar impaction.
 
What's the referring Dentist's full name? *

 
What is {{answer_13356176}}'s Practice Name & Address please?

 
The charges are £95 per arch for the CBCT 3D Scan, and £25 per model/impression STL scan (please send this with the patient). Do you want the patient to pay direct at our practice? (N.B. If not, please call ahead and make payment via telephone/BACS)

     
 
Is the patient coming with a radiographic template?

     
 
Would you like a 3D Scan of a premade silicon impression/plaster cast (for drilling guide or other uses) at the same appointment?

(Please give the patient this to bring with them)
N.B. The cost of this service is the same as a 2D OPG £25.
     
 
Which format would you like to receive the CBCT Scan?

We will provide DICOM files that can be viewed in any DICOM compatible software, if you would prefer we can provide Carestream 3D Viewer software free of charge and can even train you to plan and diagnose using this excellent software with ease.

 
Do you have any questions or comments?

 
Terms & Conditions - Please type you name at the end of reading the following to confirm you have read and agree to abide by the following terms. Referrals will not be accepted without a practitioners approval. *

Disclaimer: The results of all scans must be verified by a medical doctor to ensure accuracy before being used and compared to the medical images provided. In no event will we be liable to anyone for action taken in connection with the use of said services.
We endeavour to provide the very highest quality results, however, we will not accept any liability for incorrect or incomplete information on the Booking Form, or inappropriate or inadequate patient preparation, which may compromise the value of the final results.
We endeavour to despatch the final images to the referring Dentist/Surgeon as fast as possible, however, equipment malfunction or pressure of other work may introduce delays. We reserve the right not to accept referrals in such cases.
We will not accept any liability for consequential losses arising from delays whether because of late or non-payment, non-receipt of a Booking Form, pressure of other work, or for any other reason.
We suggest that you do not schedule an appointment to discuss the results with your patient until you have received the results from us.
We cannot guarantee that computer-readable images be compatible with your computer system.
Please note that under IR(ME)R 2000 and SI 478 of 2002 a clinical justification must be provided for each dental CT scan. Insufficient appropriate clinical information may result in the rejection of the referral.
We provide Dentists/Surgeons with Referral Forms which can be used for this purpose and accept referrals from Registered Practitioners only.
All Scans must be interpreted and reported on by an adequately qualified/trained Dentist/Surgeon/Practitioner. Reports are not provided as standard. We will not be held liable for reports not being completed by the referring dentist and by signing this agreement you are agreeing to report or have the results of the scan reported and adequately documented as soon as is practical.

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