CBCT Referral ELGIN PARK DENTAL PRACTICE

ELGIN PARK DENTAL PRACTICE

Cone Beam Computed Tomography (CBCT) is a radiographic imaging method that allows accurate, three-dimensional (3D) imaging of hard tissue structures

In addition to providing an imaging service for our own patients, we are now accepting referrals from other practices.

To refer a patient:

1. Complete the Referral Form below

2. Access our online booking system to book an appointment. Please select CT Scan as the booking reason.

3. Complete and sign the CBCT Service Level Agreement found in the referral pack if your practice has not already done so. Completed forms can be emailed to reception@elginpark.co.uk.

To download our referral pack, please click here.

REFERRING DENTIST DETAILS

Full Name:

Date Referred:

Address:

Post Code:

PATIENT DETAILS

Patient’s Name:

Date of Birth:

Address:

Home Tel:

Mobile Tel:

Work Tel:

E-mail:

PROPOSED TREATMENT DETAILS

Area Of Interest:

Radiographic template to be worn?

Yes

Justification:

Output:

Dicom

Romexis Viewer

CD-Rom/Mem Stick (£10)

I confirm the patient has consented to the sharing of their information in line with this referral:

Yes