Patient Details
Title
Name
Home Address
DOB (dd/mm/yyyy) / /
Telephone
Email
Referring Dentist Details
Title
Name
Practice Name and Address
GDC No.
Telephone
Email

Scan Regions
Type of Scan
   
     
Scan Size (Indicate Area on Diagram Below)
 
Justification for Scan (Mandatory)

Format Required
DICOM (please indicate the viewing software that you will use)
 

Scan Information
I confirm I will provide my own Radiographic Report.
Do you have a scan stent to be fitted?

Fees
All fees to be paid at the time of the appointment by the patient, please indicate that you have explained this to the patient
Scan without report  
5.5 x 5 Scan with report  
8 x 8 Scan with report  

Please Note

To comply with IMER 2000 regulations all radiographs and scans must be reviewed and reported into the clinical records by the referring practitioner or by an appropriately trained individual.

We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.

If the referring practitioner prefers that they make their own arrangements for the reporting, please let us know in advance.

How did you hear about us:
Date (dd/mm/yy): / /