The Dentists  
Contact Us
 
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
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
2nd 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 :
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)
Dental CT Scan for single tooth or jaw : £160
Dental CT Scan for both jaws : £210
Simplant conversion one jaw : £250
Simplant conversion two jaws : £370
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)  

 Verify   

Send
Copyright © Edinburgh Dental Specialists. All rights reserved. | Sitemap Dental Marketing & Website Design
by Dental Focus Web Design
About Our Edinburgh, Scotland Dentists Dental Services in Edinburgh, Scotland Dental Referrals & Fees in Edinburgh, Scotland Dental Courses in Edinburgh, Scotland Contact Our Edinburgh, Scotland Dentists Home of Edinburgh Dentists in Scotland