CBCT Referral

Dentists please complete the form below if you wish to refer patients to A&L Clinics for a CBCT scan.

We will reply to your request as soon as we can.

Patient Details

Title

Full Name

Address

Postcode

Date of Birth

Telephone

Mobile

The clinical context for requesting CBCT examination

Address

Please Select

Upper Jaw Lower Jaw Sectional Upper and Lower Jaw

Referring dentists details

Practice Name

Practice Address

Practice Email

Practice Telephone

Practice Signature

Date

Will you be reporting the CBCT yourself?

YES/NO

YES NO

(see service level agreement)

Justification

Name of IRMER practitioner

Signature

Date

Details of scan authorised

Scan information

Name of Operator

Signature

Exposure factors used

Clinical evaluation

Name of Operator

Outcome

If under the service level agreement dental CBCT images will be reported on by the referring practice, this fact should be recorded here. The referring practice will then be responsible for ensuring the clinical evaluation takes place and is properly recorded. This will act as the practitioner's electronic signature: I hereby authorize dentalessence to copy out a 3D CBCT on my behalf. When scanning guides are used, these guides will be prepared in advance by the referring dentist and given to the patient to bring to the scan appointment. The results of the scan will be returned on disc with basic viewer software. Although an evaluation of the scan will be carried out and a report supplied, I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. A and L Clinics and the Operator will not be responsible for assessing the scan for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of a CBCT Training Certificate Course is deemed a regulatory requirement for all users of CBCT systems, including those who are simply referring patients for acquisition of a CBCT image. I accept that it is my responsibility to obtain the necessary qualification in order to refer and evaluate the data requested by me and provided by A and L Clinics. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.