Referrals

CBCT Scan Referral Contact Form

To make a referral for a CBCT Scan please complete this form and save a copy for yourself before sending it to Smile Care Cosmetic Centre by email at smile@smilecareplymouth.co.uk or post a completed form to Smile Care Cosmetic Centre, 130 North Hill, Plymouth, PL4 8LA.

PATIENT DETAILS

Title

Patient’s Name *

Patient’s Address

Postcode

Date of Birth *

Tel

Mobile

Email *

REFERRING DENTIST DETAILS

Dentist’s Name *

GDC No

Practice Address

Postcode

Referral Date

Tel

Mobile

Email *

REFERRING DETAILS

Reason for referral and clinical justification for CBCT scan?

Define the anatomical area that the scan should cover:

What information do you want the dental CBCT examination to provide?

Patient to wear stent provided by dentist? yes or no

REFERRING DETAILS CONT.

OPG or Sectional 3D scan?

Justification for radiograph (this section must be completed)

Define the anatomical area that you would like the scan to cover

Mandible

Maxilla

Both Jaws

PLEASE TELL US YOUR PREFERENCES:

Patients to pay at visit

OR

Practice to pay fees

*Patient is generally given the image data to take away with them on the day – both Vatech Ez3D-i viewer and/or Raw DICOM data (to be imported into your own CT Viewing software – Simplant. iCat Vision , CS-3D etc.) The CBCT image will be reported on by the referring dentist as per your service level agreement – we can arrange for an outside source to report on findings at an additional cost. Important information: it is essential that you complete all sections of this form in full. All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

Signature of referring dentist:

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

I consent to my personal data being collected and stored for the purpose of marketing communications.

Get Us to Call You Back

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Please contact us via this website or email without disclosing confidential information.

Address

Smile Care Cosmetic Centre
130 North Hill, Plymouth, Devon PL4 8LA

Contact

Call us: 01752 663239
Email: smile@smilecareplymouth.co.uk

Opening Hours

Monday and Wednesday 8.30 AM to 6.00 PM
Tuesday, Thursday and Friday 8.30 AM to 4.00 PM