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

Please indicate the 3D CBCT area of interest

(Fees relevant to patients not registered with any dentalessence practice)

Both Jaws (£199)Mandible (£149)Maxilla (£149)small Field of view - 5x5cm or 8x5cm (£149)

Justification for scan (IRMER 2000)

Orthodontic assessment and planningImpacted teeth assessmentEndontic assessmentTMJ assessmentImplant treatment planning
(assessment of position of anatomical
structures, bone quality and quantity)

To be completed by the referring practitioner

This will act as the practitioner’s electronic signature: I hereby authorize dentalessence to carry 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 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 The Dental Practice. 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