CBCT REFERRAL FORM

REFERRER DETAILS

PATIENT DETAILS

Date of birth

Gender*

MaleFemale

Possibility of pregnancy?*

YesNo

Area of Interest:

Both Jaws (8 x 8cm)Maxilla (8 x 5cm)Mandible (8 x 5cm)Quadrant (5 x 5cm)

Patient to bring radiographic template?

YesNo

Radiographic Template Type:

Denture MarkedSeparate Template

Justification for CBCT:

ImplantsEndodonticsSinus ExamTMJOral PathologyBone GraftOrthodonticsImpacted Teeth

CBCT Format:

DICOM FilesRomexis Viewer

CBCT Output*:

CD-ROMEmail

Digital impression required? (STL file - additional £10):

YesNo

2-D Digital Panoramic (OPG) required:

YesNo

2-D Output:

YesNo

Dose Reduction Required?

YesNo