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) UR URSelect12345678 UL ULSelect12345678 LL LLSelect12345678 LR LRSelect12345678 Patient Details: Name(Required) First Last Date MM slash DD slash YYYY Address(Required) Address Line 1 City ZIP / Postal Code Phone Number Email(Required) Medical History: Please state medical history Possibility 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 Phone Email(Required) Purpose & Proposed Course Of Treatment Check all that apply Endo Implant Bone Graft Perio Impacted Teeth TMJ Ortho Other OPG CBTC Oral Surger Further information IRMER 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
