Contact Dental Specialists in Edinburgh, Scotland through Online Refferal Form

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


Copyright © Edinburgh Dental Specialists. All rights reserved. \| Sitemap	Dental Website Marketing & Dentist Websites by Dental Focus Web Design