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*
Date Format: 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
- 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*
Date Format: DD slash MM slash YYYY
Captcha
Comments
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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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