Online Secure Radiology Form

Patient Title

Patient First Name

Patient Surname

Patient Address

Patient Postcode

Patient Email

Patient Phone Number

Patient Date of Birth

Is the patient possibly pregnant?

Yes No

Referring Dentist's Details

Dentist Title

Name of Dentist

Practice Address

Practice Postcode

Referring Dentist Email Address

Dentist's Phone Number

Referral Details

What type of referral are you making

OPG Imaging CBCT Scan

OPG Imaging Only

Questions

Full image including TMJ and sinus Right side only Left side only Full image excluding TMJ and sinus

Area of Interest CBCT Only

Clinical Indications

Scan Details

Is the patient coming with a radiographic template?

Yes

Scan Selectio

Mandible

Maxilla

Both Jaws

Sectional/Quadrant

Agreement

Service-Level Agreement for the referral of patients to CENTRE OF DENTAL EXCELLENCE for Dental Cone Beam CT Examinations
This agreement is between the Referring Practice, Referring Practitioner and the Centre Of Dental Excellence

Justification:

I agree to use the referral criteria as per the European Guidelines: Radiation Protection No. 172 and provide adequate clinical information in order for each examination to be justified.
I will make my own arrangement for the reporting of the CBCT scans acquired at the Centre of Dental Excellence. This will be done by someone adequately trained as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. 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.

Reporting Option

I will make my own arrangements

Radiology report required from the Centre of Dental Excellence

Secure OPG/CBCT Referral Form

Patient Details