CBCT Referrals

Please use the contact form below to refer a patient

Alternatively you may download our PDF referral form complete and post to the practice.

Please complete all required fields marked*

Dentist Contact Details

Dentist Name*

Email*

Practice Address

Postcode

Telephone number *

Patient Details

Patient Name

Patient Address

Patient

Male

Female

Patient DOB

Patient Telephone number

Referral For:

CBT

OPG

CBCT Details

Mandible

Maxilla

Both Jaws

Sectional/Quadrant

If Sectional/Quadrant please indicate teeth to be scanned using numbers from diagram above

Is the patient coming with a radiographic template?

Yes

No

Is the patient possibly pregnant?

Yes

No

Dose Recorded

Referral Details

Clinical Indication & Justification for X-Rays

Please note - this contact form should only be used for transferring information of a non-sensitive nature. If you wish to provide us with medical information or other potentially sensitive data, please contact us by telephone on 01227 463529 and we will advise.

required fields marked *
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Bradley & Partners Dental & Implant Clinic does not routinely report upon scans and radiographs. To comply with the IMER 2000 regulations all radiographs are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We strongly recommend that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. As per your service level agreement dental CBCT images will be reported on by the referring practice. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.