CBCT Referral

CBCT SCANNING SERVICE BOOKING FORM

CBCT scans will be taken at our Morningside Practice, 27 Morningside Park, Edinburgh, EH10 5HD

CBCT Service Level Agreement

Please download a copy of our CBCT service level agreement, read sign and return to us. Once received this will be kept on file for future referrals.

Referrer Information

Patient information

Gender: Female Male

Is the patient possibly pregnant?
Yes    No

Scan Details

I would prefer to receive scans via: *
CD/USB
Email

Please note CD/USB is given to patient on day of scan

Select Format: *
VIEW ONLY (SOFTWARE INCLUDED)
RAW FORMAT

CBCT areas of interest

MANDIBLE    MAXILLA    BOTH JAWS

Reason for referral and justification for X-Ray










Please confirm if radiographic stent is required *
Yes
No

If a radiographic stent is required please note that the IR(ME)R referrer is responsible for supplying a stent that is accurate and fits correctly prior to the scanning appointment

Reporting of Scans

I fully understand and accept that Scottish Orthodontics does not report on the scans and radiographs requested by referring GDPs *
I have read and agree with Scottish Orthodontics SLA ( Service Level Agreement ) *
I am the IR(ME)R referrer/operator I am adequately trained to report on my patients scan *

Dentist Declaration

I confirm that I fully understand that to comply with IR(ME)R regulations all scans must be reviewed and reported into the patients clinical records by myself the referring GDP *

Payment Details

Payment to be made by patient
Invoice referring GDP

The information that I have given above is correct to the best of my knowledge.

For further information about how we use your data, please see our privacy policy