Make a CBCT referral

To refer a patient to Clifton Dental & Implant Clinic for a CBCT scan please complete and submit the below  form.

Please include all relevant clinical information regarding this case, and remember to attached any x-rays if relevant.

After reviewing, we will contact the patient to introduce ourselves and book them in. We will also keep you fully updated on progress throughout.

Patient details (step 1)

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Please check that the following fields have been filled out correctly:

    Referring Dentist Details (step 2)

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    Confirmation of Irmer Referrer Training *

    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)

    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 REFERRAL

    Please check that the following fields have been filled out correctly:

      Scan Details / Region of Interest (step 3)

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      Region to be scanned
      Upper Jaw Right Quadrant
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      Upper Jaw Left Quadrant
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      Lower Jaw Right Quadrant
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      Lower Jaw Left Quadrant
       1    2    3    4    5    6    7    8  

      Please check that the following fields have been filled out correctly:

        Other (step 4)

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        Please select services required

        - Please note that only the following file types are supported: jpeg, jpg, png, gif, pdf, doc, docx, xls, xlsx, rtf, ppt, odt.
        Add more files
        Confirmation

        Please check that the following fields have been filled out correctly:

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