Patient Details Name* Date Of Birth* Address* Phone Number* Email Address* Practice Details Name of Practice* Referring Dentist* Practice Address* Phone Number* Email Address* Reason for Referral* MaxillaMandibleBoth JawsZygomatic BonesSectionalEndodontic AssesmentWisdom Tooth AssessmentTMJ Other To be completed by the referring practitioner: I hereby authorise Southbank dental and Implant Centre to carry out a 3D CBCT on my behalf. When scanning guides are used, these guides will be prepared in advance by the referring dentist and given to the patient to bring to the scan appointment. The results of the scan will be returned on disc with basic viewer software. Although an evaluation of the scan will be carried out and a report supplied, I am responsible for assessing the data and referring to the necessary specialities as clinically indicated. Southbank Dental and Implant centre and the Operator will not be responsible for assessing the scan for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient, I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of a CBCT Training Certificate Course is deemed a regulatory requirement for all users of CBCT systems, including those who are simply referring patients for the acquisition of a CBCT image. I accept that it is my responsibility to obtain the necessary qualification in order to refer and evaluate the data requested by me and provided by The Implant Experts. Alternatively, I will arrange for a Consultant Radiologist to rule out coincidental pathology. Name of IRMER Practitioner* Name* GDC Number* Additional Comments Reporting* Please select one of the following: Treatment* (required) I would like my Cone Beam CT to be reported by Southbank dental, an implant centre. The service will be provided by a suitably trained and qualified member of the clinical team.I will make my own arrangement for reporting of my Cone Beam CT scans acquired at YOUR Centre. This will be done by someone adequately trained as per HPA-CRCE-010 Guidance on the safe use of Dental Cone Beam CTI will report my Cone Beam CT scans acquired at YOUR Centre. 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. Scanning and reporting fees Scanning fees: £200 – Both arches £120 – Single arch (maxilla or mandible) £120 – Smaller field of view where suitable 5×5 cm £45 – OPG Reporting fees: £60 – Small /single tooth £75 – Medium/ quadrant £120 – Large volume full arch
