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CBCT imaging referral form

"*" indicates required fields

It should be noted that under IRMER17 (The Ionising Radiation (Medical Exposure) Regulations 2017), only registered healthcare professionals may act as referrers. Due to best practice guidelines, we require dentists who refer patients to Abbeymead Dental Centre for CBCT scans to have completed Level 1 (Core CBCT) training and to have completed a Service Level Agreement (SLA) with us. We will contact you if this has not been completed before processing a CBCT scan referral.

    PATIENTS DETAILS

    Patients Name

    Patients Address

    Date of Birth

    REFERRING DENTISTS DETAILS

    Dental Practice address

    REFERRAL DETAILS

    Type of dental imaging required

    Clinical context for requesting the above examination*

    Relevant results of medical history, clinical examination and other imaging

    Define the anatomical area that the scan should cover*

    CBCT JUSTIFICATION

    All referrers need to have completed Level 1 (Core CBCT) training to be an IRMER Practitioner, to have completed a Service Level Agreement with Abbeymead Dental Centre and to give clinical justification to refer patients for a CBCT scan.

    Have you a SLA with Abbeymead Dental Centre?

    (if no, Abbeymead Dental Centre will send you a SLA to complete)

    Justifiable clinical context for requesting a dental CBCT scan*

    Please Note; Dental CBCT is not justifiable for routine diagnosis and treatment planning, general periodontal assessment, routine imaging as part of orthodontic treatment, dental caries diagnosis or as part of a general ‘screening’ procedure.

    Clinical justification includes how the CBCT scan will provide extra information to aid the patient’s management or prognosis, which cannot be gained from lower dose conventional imaging techniques.

    Field of view:

    Select those that (required)

    The CBCT image will be reported on by the referring dentist as per the Service Level Agreement.

    The referring dentist will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

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