Imaging Referral Services

Referring Dentist - Your Name

Email of the referring dentist

Practice Address

Phone number of Dentist

Urgent - Please tick either Yes or No

Yes

Name of Patient

Address

DOB

Phone

Gender

Tick box to indicate there is no contraindication to this patient receiving a Cone Beam CT Scan

Tick this box to declare that the patient is fit and scan appropriate for dental assessment, also fit and stability of stent if provided

Tick box to declare that Smile Serenity Dental Care does not report up on Scans and Radiographs requested by referring Dentists.

Purpose of scan/ Area to be scanned

I accept terms & conditions - To comply with IR(ME)R 2017 and IRR 2017 - all radiographs and scans must be reviewed and reported in to the patient records by the referring GDP or Radiologist. Scan will be provided in Dicom Format with viewing software. Payment details: Payment to be made by the patient - £105 / CBCT - £40 / OPG

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Imaging Referral Services

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