Dental CBCT Referral - Clifton Dental & Implant Clinic

Patient details (step 1)

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First name *

Last name *

Address 1

Address 2

Postcode

Date of birth *

Contact number *

Email *

Name of patient's Doctor or GP *

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Referring Dentist Details (step 2)

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First name *

Last name *

Practice name *

Practice address line 1 *

Practice address line 2

Practice city *

Practice county *

Practice postcode *

Phone number *

Email address *

Dentist's GDC No. *

Confirmation of IRMER Referrer Training *

Yes No

I have undertaken training required to satisfy the minimum criteria as an IRMER Referrer / Conebeam CT which is covered on pages 49-53 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)

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Make a CBCT referral

Patient details (step 1)

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Referring Dentist Details (step 2)

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Scan Details / Region of Interest (step 3)

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