CBCT Referral

Step 1 - Patient Details

* indicates a required field

Patient Name *:
Date of Birth:
Patient Email *:
Patient Address:
Patient Telephone (Work):
Patient Telephone (Home):
Patient Telephone (Mobile):
Name of patient's doctor or GP:

Step 2 - Referring Dentist's Details

Name of Dentist *:
Telephone:
Dentist Email *:
Dentist Address *:
Dentist's GDC Number
Confirmation of Irmer Referrer Training:
I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography)

Step 3 - Scan Details / Region of Interest

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.
Reason for Referral and Justification for the scan:
Region to be scanned:
- Small Volume (sectional Scan 4-5 teeth)
- Maxillae
- Mandible
- Both
Patient to wear stent provided by dentist?
Special instructions for operator involved in scan acquisition*:
Images will be reviewed and findings recorded by an IRMER operator (reporter) either
- Me
- We would like the scan reported
- Scans will be reported by Dr Neil Heath. The fee for reporting will be £150.

File Upload

If you are having the scan reported, please upload additional radiographs using the section below.
- CBCT scan fees:
- One Arch/Local Volume: £100.00
  Two arches: £150.00
  Report by Dr Neil Heath: £150.00
- Completed scans will be processed and handed to the patient on disc or memory stick.
Upload 1:
Upload 2:
Upload 3:
Upload 4:

Addtional Information

Relevant Medical History:

What is
endodontics?

Endodontics is also better known as Root Canal Treatment. Root Canal Treatment becomes necessary when the nerve of a tooth becomes irreversibly damaged, and therefore has to be surgically removed.

What is
prosthodontics?

A Prosthodontist undertakes the process of rebuilding or replacement of missing teeth. They are trained to deal with the aesthetic and functional challenges that replacement of teeth present.

What is
periodontics?

Periodontal disease affects the gums, bone and other supporting tissues of the teeth. Most individuals suffer gum inflammation from time to time, around 10% of the population appear to suffer from the more severe forms.

Contact us today

Get in touch with us to arrange an appointment at the practice.