Please complete for your CT Scan Referral Patient Details Patient Name (required) Patient Address (required) Patient Tel (required) Patient DOB (required) Patient Doctor/GP (required) Referring Dentist (IRMER referrer) Referrer Name (required) Referrer Email (required) Referrer Address (required) Referrer Tel (required) Referrer GDC Number (required) I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. pleaese Confirm (Guidance Notes)(required) ---YesNo Step 2. Scan Details Region to be Scanned (required) ---MaxillaeMandibleBothMaxillaeMandibleBothSpecific Area If Specific Area, Please Specify: Patient to wear stent provided by dentist ? (required) ---YesNo Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications. Please confirm (required) ---Is ConfidentIsn't Confident 2nd scan, of stent, required ? (required) ---YesNo In accordance with IR(ME)R 2000 a clinical justification must be provided for each CT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CT scans. Reason for Referral and Justification for the scan (required) Special Instructions to IRMER operator involved in scan acquisition: Images will be reviewed and findings recorded by an IRMER operator (reporter) either: (required) ---MeOther If other, What is their name: Step 3. Costs CT Scan (Includes Free viewing software on CD ROM) Dental CT Scan for single tooth, jaw or both jaws : £150 Dental CT Scan for single tooth or jaw / both jaws : £150 CT Scan Report: £100 YesNo Any Message