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

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*
Phone Number*
Email
Relevant Medical History
Possibility of pregnancy*
- Yes
- No
Scan Details
How would you like to receive the scan?*
- Dropbox
- USB
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
- UR1
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 (£85)?*
- Yes
- No
To comply with Irmer 2000 regulations, all CBCT scans are required to be reviewed and reported
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
Submitted by*
I confirm that I have received the necessary training to make this referral
Date of Referral*
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Comments
This field is for validation purposes and should be left unchanged.

Company Info

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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Contact

Aspects Dental and Referral
38 Benbow Court
Shenley Church End
Milton Keynes
MK5 6JG

Tel: 01908 506199
E-mail: info@aspectsdental.com
Fax: 01908 506507

Site Last Updated: May 22, 2018 - 12:43

ASPECTS DENTAL AND REFERRAL is a trading name of MHV SMILE CENTRE LIMITED. COMPANY REG NO 8866420

Registered Address: 38 BENBOW COURT, SHENLEY CHURCH END, MILTON KEYNES, MK5 6JG

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