Home » Cone Beam CT (3D) Scan or OPT (2D) Scan Referrals

Cone Beam CT (3D) Scan or OPT (2D) Scan Referrals

At Evesham Dental Health Team we are very grateful and honoured to accept referrals from our professional friends and colleagues. We will always respect this privilege by taking our utmost care, provide the requested advice / treatment and following completion return patients to their own practice for ongoing dental care.

How to make a referral:

• Submit online – Please complete the following form and attach any photographs, radiographs or notes you wish to include in your referral. You will receive a copy of the form sent to the practice email address you have provided.
• Click here to download a printable PDF version of the below form. Once filled in, please return to us via post.

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Practice Details

Referring Practice *

Referring Practitioner *

Practice Email *

Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Practice Telephone *

Patient Details

Patient Name *

Date of Birth *

Patient Email *

Patient Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Telephone *

Work

Mobile

Reason for referral and justification for the scan (Mandatory) and any special instructions *

Scan Information

Type of Scan (select option) *CBCT scanOPT scanOPT and CBCT scans

(pull down menu)

Patient to wear Radiographic Marker? *

• Yes
• No

Region of interest (select option) *MaxillaMandibleMaxilla and Mandible

Scan Size (Indicate Area on Diagram Below) *

• 11cm - Recommended for upper ectopic canine/ sinus/wisdom teeth/TMJ/airway evaluation
• 8cm - Normal dentition
• 5cm - Particular teeth

Layout

Upper Right

• 8
• 7
• 6
• 5
• 4
• 3
• 2
• 1

Lower Right

• 8
• 7
• 6
• 5
• 4
• 3
• 2
• 1

Upper Left

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8

Lower Left

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8

Radiographs & Clinical Photographs

If you would like to attach any radiographs, clinical photographs or any documents that you feel would be of use, please use the upload facility below.

File(s) Upload

Click or drag files to this area to upload. You can upload up to 4 files.

Your Preference *

• Patient to pay at scan appointment
• Patient to take image on Memory Stick
• OR Invoice sent to referring dentist
• OR send/post image to referring dentist

CBCT: Fee of £188.77 includes scan DICOM file on USB and Pathology Report.

OPT: Fee of £58.82 includes scan on USB or sent by email to referring dentist

CBCT and OPT: Fee of £188.77 includes scan DICOM file on USB and Pathology Report.

FORMAT DATA DELIVERY FOR CT SCAN WILL BE BY CD IN POST

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. All CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. All our CBCT scans are sent to a reporting service by a Consultant Radiologist. The resultant Pathology Report is emailed to you the referring dentist/doctor.

Patient Consent *

• I confirm I have the requisite authority to share the patient's information in connection with this referral.

I confirm I have the requisite authority to share the patient's information in connection with this referral.

Submit

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