CBCT Scan Request Form Step 1 - Patient DetailsPatient First Name*Patient Surname*Patient Address*Patient Date of Birth* Date Format: DD slash MM slash YYYY Patient Phone NumberPatient Work Phone NumberPatient Mobile Phone NumberStep 2 - Referring Dentist's DetailsName of Dentist*Dentist's Phone Number*Dentist Address*Dentist Email* Dentist's GDC Number*Confirmation of Irmer Referrer Training*YesNoI have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes)You must have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment to request a CBCT image. YOU WILL NOT BE ABLE TO CONTINUE WITH THIS REFERRALStep 3 - Scan Details /Region of InterestRegion to be scanned Small Volume (Sectional Scan) Maxillae Mandible Both Zygomas Upper Jaw Right Quadrant 8 7 6 5 4 3 2 1 Upper Jaw Left Quadrant 1 2 3 4 5 6 7 8 Lower Jaw Right Quadrant 8 7 6 5 4 3 2 1 Lower Jaw Left Quadrant 1 2 3 4 5 6 7 8 Patient to wear stent provided by dentist?*Please SelectYesNoDue to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.*Please SelectPatient Competent2nd scan, of stent, required?*Please SelectYesNoIn accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.Reason for Referral and Justification for the scan*Special Instructions to IRMER operator involved in scan acquisition*Images will be reviewed and findings recorded by an IRMER operator (reporter) eitherPlease SelectMeOther - state name belowOther - Dr Donald ThomsonNote: We are able to offer the services of Dr Donald Thomson - Specialist in Oral and Maxillofacial Radiology, for all radiographic reporting. (See below for additional fee.)Name of IRMER operator*Step 4 - CostsPlease select services required*Standard CT Scan (includes free viewing software on CD ROM or email) (Suitable for Nobelguide if you have the Nobelguide software) Dental CBCT Scan for small volume or single jaw : £99 Dental CBCT Scan for both jaws : £180 Simplant conversion one jaw : £250 (Includes cost of Scan) Simplant conversion two jaws : £370 (Includes cost of Scan) Second scan of stent for "Nobelguide" or similar : £50 Full radiology report from Dr Donald Thomson : £90 per Scan Delivery PreferenceCDEmailFile AttachmentsPlease include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx. Any Additional Comments This iframe contains the logic required to handle Ajax powered Gravity Forms. CLICK HERE for a PDF copy of our CT Scan Request Form This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.