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)

Step 2. Scan Details

Region to be Scanned (required)

If Specific Area, Please Specify:

Patient to wear stent provided by dentist ? (required)

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)

2nd scan, of stent, required ? (required)

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)

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

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