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Dental Imaging Referral Form
Use this form if you would like to refer your patient(s) for dental imaging such as Orthopantomogram (OPG) or Dental CBCT. All information are kept confidential. Please complete all sections.
Section 1: Patient's Details
Prefix
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Contact Number
*
Gender at Birth
*
Gender at Birth
Female
Male
Do not want to disclose
Email Address
*
Address
House No
*
Street Name
*
City
*
State/Province
*
Postcode
*
Country
*
Section 2: Referrer's Details
Prefix
*
First Name
*
Last Name
*
Professional Registration No.
*
Date of Referral
*
Practice Email Address
*
Practice Contact Number
*
All correspondence will be sent to this email
Practice Address
House No.
*
Street Name
*
City
*
State/Province
*
Postcode
*
Section 3: Case Details
Select types of imaging required
*
Select types of imaging required
Country
*
Case Details
*
Provide relevant medical history of the patient
*
Area of Interest
*
File Upload
*
Click to choose a file or drag here
Size limit: 10 MB
Any other relevant x-rays/imaging. medical history, patient's care summary, letters, results or photographs. 10MB limit. If exceed, please send to admin@dermdental.co.uk quoting patient's first and last initials and date of birth e.g John Smith 12 May 1965; JS12051965
Delivery Imaging Method
*
Delivery Imaging Method
CD
Practice's Email Address
Payment
*
Payment
Patient will make payment
Referring clinician or practice will make payment
IRMER 2000 Regulations: All radiographs and scans are required to be reviewed and reported into clinical notes by the referring practitioner or a radiologist. The referring practitioner is deemed to have at least CBCT Level 1 Training
*
IRMER 2000 Regulations: All radiographs and scans are required to be reviewed and reported into clinical notes by the referring practitioner or a radiologist. The referring practitioner is deemed to have at least CBCT Level 1 Training
I confirm and understand above. I have accredited CBCT Level 1 Training
Patient's Consent
*
Patient's Consent
I confirm that I have requisite authority to share the patient's information on connection with this referral
Signature
*
Referrer's Signature
Submit
