Dental imaging referral form "*" indicates required fields It should be noted that under IRMER17 (The Ionising Radiation (Medical Exposure) Regulations 2017), only registered healthcare professionals may act as referrers. Due to best practice guidelines, we require dentists who refer patients to Elmsleigh House Dental Clinic for CBCT scans to have completed Level 1 (Core) training to be an IRMER Practitioner and to have completed a Service Level Agreement (SLA) with us. We will contact you if this has not been completed before processing a CBCT scan referral. Many thanks.Patient DetailsPatient's Name* DrMissMrMrsMsProf.Rev. Title First Surname HiddenPatient First Name* HiddenPatient Surname* Patient Address* Address Line 1 Address Line 2 City County Postcode Patient Date of Birth* DD slash MM slash YYYY Patient Contact Phone Number* Patient Email* Mandatory unless no email, in which case please insert N/AHiddenPatient Home/Work Phone Number HiddenPatient Email OLD Referring Dentist's DetailsName of Dentist* Dentist's Phone Number* Dental Practice* Practice Name Practice Address City County Postcode GDC Number Dentist Email* Referral DetailsType of dental imaging required* 2D DPT/OPG Extra-oral bitewings CBCT scan Referrer needs to have completed Level 1 (Core) training to be an IRMER Practitioner, to have completed a SLA and to give CBCT justificationClinical context for requesting the above examination*Relevant results of history, clinical examination and other imagingDefine the anatomical area that the scan should cover*What information do you want the dental scan to provide?*CBCT justification All referrers need to have completed Level 1 (Core) training to be an IRMER Practitioner, to have completed a Service Level Agreement with Elmsleigh House Dental Clinic and to give clinical justification to refer patients for a CBCT scan.Have you a SLA with Elmsleigh House Dental Clinic? Yes No (if no, Elmsleigh House will send you a SLA to complete)Justifiable clinical context for requesting a dental CBCT scanDental CBCT is not justifiable for routine diagnosis and treatment planning, such as for routine implant placement or review, pre-surgical imaging of impacted lower third molars, general periodontal assessment, detection of root fractures in teeth containing metal posts, routine imaging as part of orthodontic treatment, dental caries diagnosis or as part of a general ‘screening’ procedure. Clinical justification includes how the CBCT scan will provide extra information to aid the patient’s management or prognosis, which cannot be gained from lower dose conventional imaging techniques.Field of view (all scans will be parallel to the occlusal plane unless otherwise specified): Full upper Full lower Full upper and lower Sectional Other Sectional - please specify the area*Other - please specify the area*The CBCT image will be reported on by the referring dentist as per the Service Level Agreement. If needed, you can arrange for JM Radiology to report on findings at an additional cost; for further information visit https://www.jm-radiology.co.uk, call 02039 255 920 or email support@jm-radiology.co.uk. The referring dentist will be responsible for ensuring the clinical evaluation takes place and is properly recorded.HiddenArrange for JM Radiology to report on findings at an additional cost; Yes please Signature This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.