CBCT Referral form - Scottish Centre for Excellence in Dentistry

Enter the name of the relevant clinician to refer your patient to (if known)

Region to be scanned

Upper Jaw Right Quadrant

Upper Jaw Left Quadrant

Lower Jaw Right Quadrant

Lower Jaw Left Quadrant

Patient to wear stent provided by dentist? *

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.

Reason for referral and justification for the scan *

Special Instructions to IRMER operator involved in scan acquisition *

Images will be reviewed and findings recorded by an IRMER operator/reporter who has undertaken the appropriate training and is up to date within their CPD cycle *

Name of IRMER operator

Delivery preference

Additional files
- Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.

Add more files

Patient details (step 1)

Please check that the following fields have been filled out correctly:

Referring Dentist Details (step 2)

Please check that the following fields have been filled out correctly:

Scan Details / Region of Interest (step 3)

Please check that the following fields have been filled out correctly:

If you have any questions for our team at Scottish Centre for Excellence in Dentistry, get in touch.