CBCT Referral

01903 650222

We can help provide support for CBCT imaging to provide precise spatial information that supports advanced procedures such as implant planning, assessment of impacted teeth, endodontic evaluation, and surgical case management.

CBCT Referral Form

Single/small £180 – Full/large £280 (report optional £100)

Please complete the form below to refer patients.

*Indicates required field

Patient details for CBCT referral

Address

Postcode

Date of birth

Contact number

Email

Define anatomical area for scan(s) Define anatomical area for scan(s) Upper jaw Lower jaw Sectional Upper & Lower jaw

What information do you want the CBCT to provide

Will the patient be wearing a scanning guide?

Referring dentists details

Practice address

Postcode

Practice Email

Practice contact number

Will you be reporting CBCT yourself? Will you be reporting CBCT yourself? Yes No

Justification

Practitioner Authorisation and Responsibility Statement

This serves as the practitioner’s electronic signature and formal authorisation for Findon Dental Clinic to perform a 3D CBCT scan on my behalf.

If a scanning guide is required, it will be prepared in advance by the referring dentist and provided to the patient to bring to their scan appointment.

The scan results will be supplied on a disc along with basic viewing software. While Findon Dental Clinic will conduct an evaluation of the scan and issue a radiology report only if explicitly requested, I acknowledge that I remain responsible for reviewing the data and referring the patient to the appropriate specialist as clinically necessary.

I understand that Findon Dental Clinic and the Operator are not responsible for determining treatment suitability or identifying incidental pathology. By referring the patient, I accept full responsibility for the assessment of the scan and any subsequent referrals.

In accordance with HPA CRCE-010 guidelines, attendance at an accredited CBCT Training Certificate Course is considered a regulatory requirement for all professionals using CBCT systems, including those referring patients for image acquisition. I accept that it is my responsibility to obtain the appropriate qualification to refer patients and interpret the scan data provided by Findon Dental Clinic. Alternatively, I will ensure that a Consultant Radiologist is appointed to review the scan and identify any incidental findings.