CBCT Referral Form

Please fill in the referral form below to submit a referral. Alternatively, you can download our PDF form, fill it, and return to info@aspectsdental.com

All CBCT Scans will be taken by Dr. Viren Patel or Dr. Hetal Patel.

CAPTCHA
Referrer Details
Name of Referrer*
GDC Number*
Practice Name*
Phone Number*
Email*
Address*
Street Address City ZIP / Postal Code
Patient Details
Name*
Title First Last
Date of Birth*
DD slash MM slash YYYY
Phone Number*
Email
Relevant Medical History
Possibility of pregnancy*
- Yes
- No
Scan Details
How would you like to receive the scan?*
- Dropbox
- WeTransfer
Has the patient been informed of the cost of the scan?*
- Yes
- No
Is the patient coming with a radiographic stent?*
- Yes
- No
Which areas would you like the scan to cover?
(If no areas have been selected then both arches will be scanned i.e. 110 x 80 mm)
- Mandible
- Maxilla
- Both Jaws
- Whole Sinuses
- Floor of Sinus Only
Upper Right
- UR8
- UR7
- UR6
- UR5
- UR4
- UR3
- UR2
- UR1
Upper Left
- UL1
- UL2
- UL3
- UL4
- UL5
- UL6
- UL7
- UL8
Lower Right
- LR8
- LR7
- LR6
- LR5
- LR4
- LR3
- LR2
- LR1
Lower Left
- LL1
- LL2
- LL3
- LL4
- LL5
- LL6
- LL7
- LL8
Please select a scan size
(If known)
- 40 x 40 mm
- 60 x 60 mm
- 80 x 80 mm
- 1100 x 80 mm
Would you like our radiologist to write a radiology report of the scan?*
To comply with IRMER 2000 regulations, all CBCT scans are required to be reviewed and reported. The reporting responsibility rests with the referring dentist and we will not report on the scan unless instructed by the referring dentist, (additional £150).
- Yes
- No
Justification for scan*
- Implants
- Bone Graft
- Periodontal Assessment
- Post-Op Low Dose
- Endodontics
- Sinus Examination
- TMJ Assessment
- Oral Pathology
- Impacted Teeth
- Orthodontics
- Other
Other*
Please give more details
Upload documents
Please attach any radiographs or documents that may be useful to us here. Maximum file size is 32MB, to upload larger files, please contact us at info@aspectsdental.com
Drop files here or

Max. file size: 32 MB.
Submitted by*

I confirm that I have received the necessary IRMER training to make this referral
Date of Referral*
DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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About Aspects Dental

Aspects Dental & Referral based in Milton Keynes is a state of the art Private Dental Practice that offers General Dentistry Services and Cosmetic Dental Treatment. Welcome to World Class Smiles. Read more...

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