CBCT Scan Referral Form – Scottish Centre for Excellence in Dentistry

Have you completed an SLA?*

Yes
No

Service Level Agreement

Service - Level Agreement for the referral of Patients to the Scottish Centre for Excellence in Dentistry for Cone Beam CT Examinations

Referral criteria for dental CBCT:

The document specified below will be used by both parties as the basis for the referral of patients and the justification/authorisation of dental CBCT examinations:

Entitlement of Persons

Enter bellow the details of all persons at referring practice who will refer patients for dental CBCT examinations and/or report on dental CBCT images. The referrer holds evidence of training meeting the requirements of the HPA/BSDMFR Core Curriculum in the Dental CBCT.

Name	GDC/GMC Reg No	IRMER ROLES	TRAINED

Signatures of Agreement:

We the undersigned agree: (1) to use the referral criteria stated above; (2) that evidence of adequate training has been obtained for each person named above appropriate to their IRMER roles; (3) that adequate information will accompany each referred patient to allow the justification process to proceed, as set out in the Referral form.

Name of clinician completing the SLA*

Signature of Clinician*

Click here when you've completed the form above*

I've completed the SLA

Referral Form

Patient Details

Patient Name*

Prefix First Last

Patient Address*

Address Line 1 Address Line 2 City Postcode

Patient Date of Birth*

Best Time to Call

Patient Phone Number

Patient Mobile Phone Number

Patient Email Address

PLEASE COMPLETE DETAILS BELOW FOR AN EXAMINATION REQUEST FOR EITHER I-CAT DENTAL CT OR CARESTREAM SECTIONAL

Please choose what sort of referral you need*

Which clinician are you referring to?

CARESTREAM CT REFERRAL

Two arch scan (8 cm x 9 cm)*—capture both dental arches in a single scan for cases that involve a larger area
Single arch scan (8 cm x 5 cm)—ideal for cases that require a full view of either mandible or maxilla, including implant planning with surgical guide creation and oral surgeries
Sectional scan (5 cm x 5 cm)—the ideal compromise of image size and dose, this mode ensures you receive the details you need, with no unnecessary information; ideal for most local dental applications
EndoHD sectional scan (5 cm x 5 cm; 75 µm resolution)—high-resolution mode delivers maximum precision for exams that require greater visibility of the patient’s root and/or canal morphologies; best-suited for endodontic applications
Pediatric program (4 cm x 4 cm)—limit patient exposure by confining radiation to a small area; a great option for younger patients, implant planning, and follow-up exams

Please choose your Carestream CT Referral type

ICAT Referral

Please choose from the following

Reason for referral and justification for CBCT scan

Imaging Stent Required

Scan Report Required (Additional Fee)

By selecting No to scan report, I understand that the CT scan is an acquisition only service and does not include interpretation

Relevant Medical History

PLEASE NOTE: Images will be sent via email only

Referring Dentist's Details

Name of Dentist*

Dentist's Phone Number*

Address of Dentist*

Address Line 1 Address Line 2 City Postcode

Dentist Email*

Dentist GDC Number

Add to mailing list*

Delivery

CBCT will be sent via email.

File Attachment

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.