CBCT Referral

We welcome referral of  your patients for use of our  CBCT Scanner.

Please complete the referral form below and a member of our team will be in touch. We will invoice you patient for the scan on the day and aim to forward all scans within 48 hours of them being taken. If you require the data more urgently please contact our reception team on 0131 669 2114 after the form is submitted.

    Patient Details

    Name

    DOB

    Address

    Tel. Home

    Tel.Mob

    e-mail

    Postcode

    Reason for referral and justification for the scan 

    View Requested small volume 4-5 teethmaxillamandibleboth archesother

    Additional details

    Referring Dentist Details

    I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes) 

    Yes I consent to my personal data being collected and stored as per the Privacy Policy.