Referral Form Please fill out any relevant information on this form. One of our team will then contact the patient to arrange a suitable time to book the first appointment. The patient will only be treated for the procedure specified by you in the referral and we will refer them back to you for all other care. Additional fields may appear depending on your selections, specifically for the CBCT scan section. Patient DetailsPatient First Name(Required)Patient Surname(Required)Patient Address(Required) Address Line 1 Address Line 2 City Postcode Patient Phone NumberPatient Email Patient Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referring Dentist's DetailsName of Dentist(Required)Dentist's Phone Number(Required)Address of Dentist(Required) Address Line 1 Address Line 2 City Postcode GDC Number(Required)Referral DetailsSelect the type of referral(Required) Implant placement only Implant + restoration Bone augmentation Sinus lift Soft tissue augmentation Parafunction Advanced restorative Oral surgery CBCT Scan CBCT Referral Please note we cannot proceed with the CBCT without appropriate justification, so please ensure this is completed fully to avoid any delays.IRMER Trained(Required) I can confirm I am IRMER trained to prescribe and report CBCT radiographsReporting We do not routinely provide a report on the CBCT radiographs taken. Please tick here if you would like us to provide this service and charge you for it.FOV(Required) 90x80mm - whole of both maxilla and mandible 50x80mm 50x50mm 50x80mm(Required) maxilla mandible 50x50mm Please name the area you require(Required)Justification for CBCT(Required)What information do you want the dental CBCT examination to provide?(Required)Examples: I would like to investigate the local anatomy and ridge morphology as part of my treatment planning process. Please expose both sides of maxilla to include all teeth crowns and roots, alveolar bone, floor of both maxillary sinuses and floor of nose. I would like to investigate local anatomy, ridge morphology and course and dimensions of IDB’s as part of my treatment planning process. Please expose both sides of mandible to include all teeth crowns and roots, alveolar bone, extending to inferior border of mandible.Does the patient need to wear a radiographic stent for the exposure?(Required) No Yes. I have constructed a radiographic stent, and the patient is able to insert and remove it independently. Please ensure it is inserted for the exposure and take a second CBCT of the stent at an appropriately reduced dose. Additional Referral DetailsRelevant Medical Details(Required)Summary of Clinical ObservationFile AttachmentPlease include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB. This form is being sent securely via the Valident vForms service ensuring safe transmission of your data in accordance with our Privacy Policy.
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