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 email@example.com CAPTCHAReferrer DetailsName of Referrer* GDC Number* Practice Name* Phone Number*Email* Address* Street Address City ZIP / Postal Code Patient DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Date of Birth* DD slash MM slash YYYY Phone Number*Email Relevant Medical HistoryPossibility of pregnancy* Yes No Scan DetailsHow 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 for scans up to 8x8cm & £150 for 11x8cm scans) To comply with Irmer 2000 regulations, all CBCT scans are required to be reviewed and reported 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 detailsUpload documentsPlease 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 firstname.lastname@example.org Drop files here or Select files Max. file size: 32 MB. Submitted by* I confirm that I have received the necessary training to make this referralDate of Referral* DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged.