Referral for X-rays & CBCT Scan Southend on Sea

CBCT EXAMINATION REFERRAL DETAILS

Full Arch *MaxillaMandible

Imaging stent supplied by referring dentists *

YesNo

Imaging stent required *

YesNo

PATIENT DETAILS

Patient name *


Title	First	Last	Suffix

Date of birth *

Address

Street Address *

Address Line 2

Postal / Zip Code *

City

Country

Possibility of pregnancy *

YesNo

Phone (Mobile) *

Phone (Work)

Email *

MEDICAL HISTORY

Please state medical history

Radiographs available *

YesNo

REFERRING DENTIST'S DETAILS


First Name	Last Name

Date

Address

Street Address

Address Line 2

Postal / Zip Code

City

Country

Phone Number

Fax

Email *

PURPOSE & PROPOSED COURSE OF TREATMENT

Further information *

Payment *

Patient to payAccount to referrer

IRMER 2000 Regulations: We do not routinely report on scans or radiographs. To comply with the IRMER 2000 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We can arrange for a report to be prepared by a Consultant Radiologist if this is requested by you.

Please choose *I have added my patient’s medical history in the notes above for this radiographic examination to be reported upon by a Consultant RadiologistI will make my own reporting arrangements

Please leave this field empty.

Monday	9.00am to 5.00pm
Tuesday	9.00am to 5.00pm
Wednesday	9.00am to 5.00pm
Thursday	9.00am to 5.00pm
Friday	9.00am to 4.00pm
Saturday	By Appointment Private only

Dentist Referrals

X-RAY and CBCT REFERRAL DETAILS

CBCT EXAMINATION REFERRAL DETAILS

PATIENT DETAILS

MEDICAL HISTORY

REFERRING DENTIST'S DETAILS

PURPOSE & PROPOSED COURSE OF TREATMENT

Advanced Dental Aesthetics

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