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Secure CBCT Scan/OPT Referral Form

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Patient Details

Title Surname Forename Address Postcode
Date of Birth Tel (Home) Tel (Work) Tel (Mobile) Email

Referring Practitioner

Name Address Postcode
Telephone Email

Medical History

Reason for referral and justification for CBCT Scan/OPT

Examination Request for Dental CBCT
Please select area(s) for CBCT scan Imaging stent provided
Image Management for Digital OPT
OPT on photographic paper
OPT on CD
OPT as email attachment
Image Management for Dental CBCT
CBCT Scan on CD
CBCT Scan emailed
CAPI Ltd does not routinely report upon scans and radiographs. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported on the clinical notes by the referring practitioner or by a radiologist. CAPI Ltd strongly recommends that all CBCT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. CAPI Ltd offers a reporting service by a Consultant Radiologist.

I would like this patient's radiographic examination to be reported upon by your Consultant Radiologist (£90)
I will make my own reporting arrangements
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