CBCT Referral

Dentists please complete the form below if you wish to refer patients to dentalessence for a CBCT scan.

We will reply to your request as soon as we can.

    Your Practice Details (please ensure this section is fully completed)

    * Indicates a required field

    Patient Details

    The clinical context for requesting CBCT examination

    Define the anatomical area that the scan(s) should cover *

    Please select

    Upper Jaw (£149)Lower Jaw (£149)Sectional (£149)Upper and Lower Jaw (£199)

    Referring dentists details

    Date

    Will you be reporting the CBCT yourself?

    YESNO

    (see service level agreement)

    Justification

    Name of IRMER practitioner

    Signature

    Date

    Details of scan authorised

    Scan information

    Name of Operator

    Signature

    Exposure factors used

    Clinical evaluation

    Name of Operator

    Outcome

    If under the service level agreement dental CBCT images will be reported on by the referring practice, this fact should be recorded here. The referring practice will then be responsible for ensuring the clinical evaluation takes place and is properly recorded. This will act as the practitioner's electronic signature: I hereby authorize dentalessence to copy out a 3D CBCT on my behalf. When scanning guides are used, these guides will be prepared in advance by the referring dentist and given to the patient to bring to the scan appointment.

    The results of the scan will be returned on disc with basic viewer software. Although an evaluation of the scan will be carried out and a report supplied, I am responsible for assessing the data and referring to the necessary specialties as clinically indicated.

    dentalessence and the Operator will not be responsible for assessing the scan for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of a CBCT Training Certificate Course is deemed a regulatory requirement for all users of CBCT systems, including those who are simply referring patients for acquisition of a CBCT image. 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 dentalessence. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.

    Dentist Referrals

    We also provide the following services on a referral basis.
    Please click on the links below for the individual referral forms.

    Hygienist Referral Form
    Implant Referral Form
    OPG Referral Form
    Oral Surgery Referral Form