CBCT Referral Form – Artisan Implants Blackheath

CT Scan/Imaging Referral Form

Dr Umer Daood

192 Westcombe Hill, Blackheath, London SE3 7DH

Tel: 020 8016 2209

Dentists - Please Fill-in the Form

*CBCT will be provided on a CD with Eazy 3D Plus Viewing Software

Referring Practitioner / Clinic Details

Referrer's Full Name

Dental Practice Name*

Dental Practice Address*

Dental Practice Post Code*

Practice Phone Number*

Practice Email*

Date of referral*

Patient Details

Patient Name*

Patient Date of Birth*

Patient Address*

Patient Post Code*

Patient Email*

Patient Mobile Telephone*

Examination Required

Area of Interest (CBCT Only)

Area of Interest

Clinical Indications (Justification for the Radiograph)

Please Sign Below by Retyping Your Name

Signaturename

IR(ME)R Regulations:

To comply with the regulations, all radiographs must be clinically evaluated to rule out the possibility of coincidental pathology. Artisan Implants does not report on dental scans or x-rays; by referring for dental imaging, the referrer accepts the responsibility for arranging reporting. By referring patients for the X-ray or CBCT Scan Artisan Implants assume that the referring clinician has got the required training and experience to read, understand and report on the scans or radiographs.

At Artisan Implants, the Operator will take a scan with the lowest dose, smallest field of view and best resolution, according to the area of interest and clinical indications, in line with IR(ME)R and ALARP.

192 Westcombe Hill,
Blackheath,
London SE3 7DH

020 8016 2209

Monday – Friday: 9am – 5pm

Tel: 020 8305 0606

020 8016 2209

CT Scan/Imaging Referral Form

Dentists - Please Fill-in the Form

IR(ME)R Regulations: