CBCT Referral form - Wargrave Dental Clinic

Please ensure you complete ALL mandatory fields. Failure to provide details will delay scans.
You can also download a PDF version of the CBCT Referral Form and email the completed form to us info@wargravedentalclinic.co.uk or send by post to: Wargrave Dental Clinic, 68a High Street, Wargrave, RG10 8BY

REFERRING DENTIST DETAILS

GDC No.(Mandatory)

Preferred contact number(Mandatory)

Practice Name(Mandatory)

Email(Mandatory)

PATIENT DETAILS

Email(Mandatory)

Telephone Number(Mandatory)

Possibility of pregnancy(Mandatory)

Purpose of Examination

Other:

If other please give details

Field of View (FOV) Available

This is to ensure you have the required information for your clinical needs and achieved with a dose as low as is reasonably practicable (ALARP). Complying with IMER 2000 and IRR99 regulations.

Extra Information

Any other information you would like to supply? e.g. specific imaging parameters / protocols / concerns /FOV considerations / Is the patient attending with a radiographic stent?