CT SCAN DENTAL REQUEST FORM

Step 1

Patients Details

Referring Dentist
(IRMER referer)

Patient's Name :

Name :

Email :

Patient's Address :

Address :

Postcode :

Tel :

Dentist's GDC No. :

D.O.B :

Name of patients Doctor or GP :

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

This will become a mandatory field from 1st Sept 2012 in this Practice

Click to view the guidance notes

Step 2

Scan Details

Region to be Scanned :

Maxillae Mandible Both

Patient to wear stent provided by dentist ?

Yes No

Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications

2^nd scan, of stent, required ?

Yes No

In accordance with IR(ME)R 2000 a clinical justification must be provided for each CT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CT scans.

Images will be reviewed and findings recorded by an IRMER operator (reporter) either :

Other (please state name)

Note: We are able to offer the services of Dr Neil Heath - Specialist in Oral and Maxillofacial Radiology, for all radiographic reporting.
(See below for additional fee.)

Step 3

COSTS

1. Standard CT Scan (Includes Free viewing software ICAT vision on CD ROM. (Suitable for Nobelguide if you have the Nobelguide software)

	Dental CT Scan for single tooth or jaw	:	£160
	Dental CT Scan for both jaws	:	£210
	Simplant conversion one jaw	:	£250 (Includes cost of Scan)
	Simplant conversion two jaws	:	£370 (Includes cost of Scan)
	Second scan of stent for "Nobelguide" or similar	:	£50
	Full radiology report from Dr Neil Heath, Specialist in oral and maxillofacial radiology	:	£80 per Scan

Step 4

IRMER operator (acquisition) Use Only

Appt. Date			Print operator name

Appt. Time			Confirmation of scan justification by IRMER "practitioner"

			Date:

Field of View (cm)			Voxel Size (mm)

Duration (seconds)

mAs

Effective Dose (mSv)

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