Referral Form for CBCT Full Name GDC Number Date of Referral Practice Address Postcode Contact Number Email Address Referring dentist has undertaken additional IRMER training in CBCT scans YesNo Patient Name Date of Birth Patient's Address Postcode Contact Number Home Contact Number Mobile Email Address Purpose of Scan (Justification) Tick to confirm there is no medical contraindication to this patient receiving a CBCT scan I confirm the patient is fit to have a CBCT scan, is aware of radiation risk and cost involved prior to scanning and the scan is appropriate for dental assessment. Practitioner's Signature Date Submit Your Referral
