Imaging Referral Form

Referral criteria for dental CBCT:

The document specified below will be used by both parties as the basis for the referral of patients and the justification/authorisation of dental CBCT examinations:

Entitlement of Persons

Enter bellow the details of all persons at referring practice who will refer patients for dental CBCT examinations and/or report on dental CBCT images. The referrer holds evidence of training meeting the requirements of the HPA/BSDMFR Core Curriculum in the Dental CBCT.

Referral criteria for dental CBCT:

Entitlement of Persons

Signatures of Agreement:

Referral Form

Step 1 - Patient Details

Step 2 - Referring Dentist's Details

Step 3 - Scan Details /Region of Interest

Step 4 - Costs

Delivery

Imaging Referral Form

Referral criteria for dental CBCT:

Entitlement of Persons

Signatures of Agreement:

Referral Form

Step 1 - Patient Details

Step 2 - Referring Dentist's Details

Step 3 - Scan Details /Region of Interest

Step 4 - Costs

Delivery

You are now in a secure area