Request a CBCT referral Fields marked is required must be completed Practitioner Details Name of IRMER Practitioner GDC Number Practice Name Practice Telephone is required Practice Email is required Practice Address Patient Details Patient Name is required Patient Telephone is required Patient Email Patient Date of Birth R.M.H Patient Address Imaging Required Digital Orthopantomagraph Digital Cephalometric CBCT Area of interest (CBCT ONLY) Mandible Maxilla Both Jaws Specific teeth Define the anatomical area that the scan(s) should cover Is the patient coming with a radiographic template? Yes No CBCT Details The clinical context for requesting a dental CBCT examination Relevant results of history, clinical examination and other imaging What informaton do you want the dental CBCT examination to provide? In submitting your information you agree to our privacy policy.
