CBCT Referral Form – Toothwise

Referring Dentist Details

Name

GDC Number

Practice Address

Address Line 1

Address Line 2

City

Postcode

Telephone Number

Email Address

Patient Details

Name

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

Postcode

Telephone Number

Patient Email Address

Justification

Reason for CBCT

Please specify

What information do you want the CBCT examination to provide?

Describe specific anatomic structures requiring visualisation (i.e. maxillary sinus, inferior alveolar canal etc.)

Any additional information

Area of Interest

Sectional (5x5cm3) 4 teeth max

Maxilla (8x5cm3)

Mandible (8x5cm3)

Has the patient been given any appliances to wear for the CBCT (e.g. scan guide)?

If so, please specify below.

Reporting of Scan

I confirm I am a qualified IRMER referrer (minimum CBCT Level 1 Core Training) and I am aware that Toothwise Hurworth Dental Practice will not be providing a reporting service of the CBCT request*

Clinician Authorisation for Referral

Signature

Sign Here

Date of referral

Service Level Agreement for the Referral of Patients To Hurworth Dental Practice for Dental Come Beam CT Examinations

This agreement is between:

Hurworth Dental Practice
5 Church Row
Hurworth
Darlington
Co. Durham
DL2 2AQ
01325 721999
Dental.v01293@nhs.net

Clinician

Address

Zip Code

Tel

GDC number

Justification

I agree to use the referral criteria as per the European Guidelines: Radiation Protection No. 172 and provide adequate clinical information in order for each examination to be justified

Reporting (please tick one of the following)

I will make my own arrangement for the reporting of my Cone Beam CT scans acquired at Toothwise – Hurworth Dental Practice. This will be done by someone adequately trained as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT

I will report my Cone Beam CT scans acquired at Toothwise – Hurworth Dental Practice. I confirm that I am adequately trained to interpret cone beam CT scans as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. I will ensure that my training remains up to date

These guidelines are available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340159/HPA-CRCE-010_for_website.pdf

Referring Clinician

Signature

Sign Here

Date