CBCT Referral Form Referring Dentist Details Dentist First Name Dentist Surname Phone Number Email Patient Details Patient's Title —Please choose an option—MrMrsMsDrProf Patient's Name Patient's Date of Birth Patient's Phone Number Patient's Email for Confirmation Patient's Gender MaleFemale Payment Type DoctorPatient Earliest date to scan the patient Please select which services you require for this Patient CBCT Scans2D Imaging The Radiographer will take a scan with the lowest dose, smallest field of view and best resolution, according to the area of interest and clinical indications, in line with IR(ME)R and ALARP. The age, anatomy and physical build of the patient are all dependent factors. CBCT Scans Indicate Teeeth and Area of Interest Is the patient coming with a radiographic template?* NoYes Clinical Indications* Select Teeth If no area is selected the whole jaw will be scanned CBCT Area of Interest* —Please choose an option—SectionalQuadrantMandible (Lower Jaw)Maxilla (Upper Jaw)Both JawsBoth Jaws (Ortho) Dose reduction technology CBCT Format Please note that we only provide DICOM files for the CBCT CBCT Output You will receive e-mails with notifications when results are ready. You can also choose an additional output format, from the following options: E-mailUSB Justification for X-Ray ImplantsEndodonticsSinus LiftBone GraftRamos Bone GraftOrthoOral PathologyTMJPerioChin Bone GraftImpacted TeethSinus ExamZygomatic ImplantsAirway Study
