Referral Form for CBCT Patient Details First Name Surname Patient Email Patient Phone Number Patient Date of Birth Patient Address Address Line 2 City Postcode Referring Dentist Dentist First Name Dentist Surname Dentist Telephone Dentist Email Practice Address Address Line 2 City Postcode CBCT Details Referring dentist has undertaken additional IRMER training in CBCT scans Purpose of Scan (Justification) Suitability Confirmation 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
