Dental CT Scan Request Form

Patient Title*
—Please choose an option—MrMrsMissMsDrOther

Patient Name*

Patient Address*

Patient Date of Birth*

Patient Telephone*

Patient Mobile Phone*

Patient Doctor/GP*

Referrer Name*

Referrer Email*

Referrer Address

Referrer Telephone*

Referrer GDC Number*

I 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)*
—Please choose an option—YesNo

Region to be Scanned*
—Please choose an option—MaxillaeMandibleBoth

Patient to wear stent provided by dentist?*
—Please choose an option—YesNo

Due 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 choose an option—Patient Competent

2nd scan, of stent, required?*
—Please choose an option—YesNo

Reason for Referral and Justification for the scan8

Special Instructions to IRMER operator involved in scan acquisition:*

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