Strathbungo Dental

CBCT Referral Form

For referrals from suitably trained dental practitioners. Please provide enough clinical information to allow appropriate justification and scan planning.

Patient Details

Patient full name* Date of birth* Telephone Email

Patient address Pregnancy status / possibility of pregnancy

Referring Dentist Details

Dentist name* GDC number* Practice name* Practice telephone

Email for correspondence* Practice address

CBCT Request

Site / region of interest* Clinical indication*

CBCT justification / clinical question* Relevant symptoms, clinical findings or history Previous imaging available?

Reporting Requirements

Do you require a CBCT report?*

Uploads

Upload any relevant radiographs, referral letters or clinical photographs.

Upload files

Declarations

I confirm I have completed appropriate Level 1 / core CBCT training and am competent to refer for CBCT imaging. I confirm the referral contains sufficient clinical information for justification and that the anticipated diagnostic benefit outweighs the radiation risk. I confirm the patient has been informed of the reason for referral and consents to their details being shared for this purpose. Additional notes

CBCT Referral Form

Patient Details

Referring Dentist Details

CBCT Request

Reporting Requirements

Uploads

Declarations

Location

Hours

Contact