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Referral Form
CT Scan Request Form
Location
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Referral Form
CT Scan Request Form
Location
Edinburgh Dental CT Scan Request Form
CT SCAN DENTAL REQUEST FORM
Step 1
Patients Details
Referring Dentist
(IRMER referer)
Patient's Name :
Name :
Email :
Patient's Address :
Address :
Postcode :
Tel :
Tel :
Dentist’s GDC No. :
D.O.B :
Name of patients Doctor or GP :
Step 2
Scan Details
Region to be Scanned :
Maxillae
Mandible
Both
Patient to wear stent provided by dentist ?
Yes
No
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.
Reason for Referral and Jusification for the scan
Special Instructions to IRMER operator involved in scan acquisition:
Images will be reviewed and findings recorded by an IRMER operator (reporter) either :
Me
Other (please state)
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)
Cost for single tooth or jaw
:
£160
Cost for both jaws
:
£210
Second scan of stent for "Nobelguide" or similar
:
£50
Full radiology report from Dr Neil Heath specialist in oral and maxillofacial radiology
Per scan
:
£80
Step 4
SIMPLANT RE-FORMATTING INSTRUCTIONS
If you already have, or wish to use SIMPLANT planning software, in order to reduce costs, we now recommend booking directly through the IDT website. Please follow this link to the correct booking page and type in: “Edinburgh dental specialists” in the key word search.
http://www.ctscan.co.uk/search/hosp_info.php?id=3&hosp=12
Guide line Total costs for SIMPLANT reformatted scans (including the cost of the scan and delivered by e-mail) are:
Cost for one jaw
:
£250
Cost for both jaws
:
£210
Step 5
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)
Verify
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