REFERRAL FORM

    Practice Details

    Patient Details

    3D CBCT area of interest


    Both Arches
    Mandible
    Maxilla
    Small Field of View - 5x5cm or 8x5cm
    OPG

    Justification for scan (IRMER 2000):


    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

    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.


    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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