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 A CARESTREAM SECTIONAL

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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

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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.