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01315563240
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CBCT FORM
Step 1 - Referrer Information
Practitioner Name*
Practice Name*
Practice Address*
Practice Contact Number*
Practitioner Email Address
Step 2 - Patient Information
Patient First Name*
Patient Last Name
Post Code
Patient Address
Patient Date of Birth
Patient Contact Number*
Patient Email Address
Gender
Male
Female
Is the patient possibly pregnant?
Yes
No
Step 3 - Scan Details
CBCT Areas of Interest
Mandible
Maxilla
Both Jaws
Reason / Justification for CBCT*
Define Anatomical Area*
What information do you want the CBCT to provide?*
Special Instructions / Further Notes
Radiographic Stent Required?
Yes
No
Step 4 - Reporting & Declarations
I fully understand and accept that Bellevue Dental does not report on the scans and radiographs requested by referring GDPs*
I have read and agree with Bellevue Dental SLA (Service Level Agreement)*
I am the IR(ME)R referrer/operator, adequately trained to report on my patients scan*
I confirm that I fully understand that to comply with IR(ME)R regulations all scans must be reviewed and reported into the patients clinical records by myself the referring GDP*
Payment Details
Patient
Invoice referring GDP
The information that I have given above is correct to the best of my knowledge*
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