Download PDF Version
Patients Name: (required)
Patients Address: (required)
Date Of Birth:
Reason for referral and clinical justification for CBCT scan
If sectional view requested please state 4 teeth of most importance
Define the anatomical area that the scan should cover
What information do you want the dental CBCT examination to provide?
Patient to wear stent provided by dentist ?
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 confirm (required)
I am the IRMER referrer/operator. I am adequately trained to report on my patient’s scan. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We advise that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.
Website by: The Design Department