Referral form

Please fill in the form below.

Patient Details

Name:

Date Of Birth:

Address:

Telephone:

Scan Details

The clinical context for requesting a dental CBCT examination:

Region to be scanned:

 Maxilla Mandible Both

Report Required:

 Yes No

Fee:

Patient to wear stent provided by dentist:

 Yes No

What information do you want the dental CBCT examination to provide?

Referring

GDP:

Address:

Telephone:

Patient to pay direct to SB?

 Yes No

Date of Referral:

Name of IRMER practitioner and Scan Operator : Nigel M. Jones


Case Study: Buried Root

Mr GD from Swansea (West Wales). Mr D was a self-referral and not aware of the buried canine in his upper left jaw...
View Case Study

Case Study: Lingual Shelf

Mr AA from Newport (South Wales). From the 2-D image (DPT view) it appears that there is plenty of bone height above the...
View Case Study

Case Study: Endodontic

Mrs AE from Usk (Monmouthshire). A two dimensional image of this tooth would not show the true extent of the roof-fracture...
View Case Study

Case Study: Maxillary Sinus

Mr NM from Crickhowelll (Powys). The 2D OPT image for Mr M helped us realise the extent of the maxillary sinuses and the resulting lack of bone height...
View Case Study

Website was last updated at 02/08/2017 | General Dental Council