Referrals Digital Panoramic Referral Details:Digital Panoramic(Required) Not Required Required with TMJ Required without TMJ CBCT Examination Referral Details:Full Arch(Required) Maxilla Mandible Both Jaws Imaging stent supplied by referring dentists *(Required) Yes No Imaging stent required Yes No Small volume (please indicate, If no teeth are selected, the whole jaw will be scanned)URURSelect12345678ULULSelect12345678LLLLSelect12345678LRLRSelect12345678Patient Details:Name(Required) First Last Date MM slash DD slash YYYY Address(Required) Address Line 1 City ZIP / Postal Code Phone NumberEmail(Required) Medical History:Please state medical historyPossibility of pregnancy Yes No Referring Dentist's Details:Name First Last Dentist GDC Number(Required)Date MM slash DD slash YYYY Address(Required) Address Line 1 City ZIP / Postal Code PhoneEmail(Required) Purpose & Proposed Course Of TreatmentCheck all that apply Endo Implant Bone Graft Perio Impacted Teeth TMJ Ortho Other OPG CBTC Oral Surger Further informationIRMER 2017 Regulations: We do not routinely report upon referred scans or radiographs. To comply with the IRMER 2017 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We strongly recommend that all CT and other radiographic examinations should be reported upon to rule out the possibility of co-incidental pathology.Please choose(Required) Please supply a radiologist's report. I have added my patient's medical history in the notes above. I undertake to report on the scan/s as required by IRMER 2017. How did you hear about us?How did you hear about us?Please SelectGoogle / Search engineDisplay AdFacebookTikTokInstagramFrom a friendOther
