Radiograph Referral Form

REFERRING PRACTISE DETAILS

Practice Name

Practice Address

Street Address Address Line 2 City County Postcode

Email*

Practice telephone*

Patient Name*

Prefix First Last

Patient Address

Street Address Address Line 2 City County Postcode

Patient Date of Birth

Patient Contact Number*

Patient Email*

Please choose from one of the following:

Please stipulate the exact teeth/area you require e.g. "Upper left 3 - 6":*

Please select all that apply from the list below:

Implant treatment planning (assessment of position of anatomical structures, bone quality and quantity) OR
Orthodontic assessment and planning OR
Endodontic assessment OR
Wisdom teeth assessment:
- UR8
- UL8
- LL8
- LR8
TMJ

Other (Please specify):

Name of IRMER Practitioner*

First Last

GDC Number*

Additional Comments:

Attach an X-ray

Drop files here or

Max. file size: 64 MB.

Reporting:*

Please select one of the following:

I would like my Cone Beam CT to be reported by Gallions Dental. The service will be provided by a suitably trained and qualified member of the clinical team.
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.

We'll keep in touch with you regarding any courses and events we may hold, which we think you will find useful.

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