Radiograph Referral Form

Practice Name (*)

Practice Address Line 1

Address Line 2

City

Postal Code

Email (*)

Phone Number (*)

Patient Name (*)

Patient Date of Birth (*)

Patient Address Line 1

Address Line 2

City

Postal Code

Patient Email (*)

Patient Phone Number (*)

Please choose from one of the following:
Both Arches
Mandible
Maxilla
Small Field of View - 5x5cm or 8x5cm
OPG

Please stipulate the exact teeth/area you require e.g. "Upper left 3 - 6":*

Please choose from one of the following:
Implant treatment planning (assessment of position of anatomical structures, bone quality and quantity)
Orthodontic assessment and planning
Endodontic assessment
Sinus graft
Wisdom teeth assessment
LL8
LR8

Other (Please specify):

To be completed by the referring practitioner: This will act as the practitioner’s electronic signature: I hereby authorise Oak Hill Dental to carry 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 a USB with basic viewer software. Although an evaluation of the scan will be carried out I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Oak Hill Dental 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 Oak Hill Dental. Alternatively, I will arrange for a Consultant Radiologist, or a suitable individual, to rule out coincidental pathology.

Name of IRMER Practitioner (*)

GDC Number (*)

Additional Comments:

Reporting: (*)
Please select one of the following:
I will make my own arrangement for reporting of my Cone Beam CT scans acquired at YOUR Centre. This will be done by someone adequately trained as per HPA-CRCE-010 Guidance on the safe use of Dental Cone Beam CT
I will report my Cone Beam CT scans acquired at YOUR Centre. I confirm that I am adequately trained to interpret cone beam CT scans as per HPA-CRCE-010 Guidance on the safe use of Dental Cone Beam CT. I will ensure that my training remains up to date.

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