Dentist in Whitchurch, Hampshire
Whitchurch Practice

67, Winchester Road, Whitchurch,
Hampshire, RG28 7HW

Andover Practice

Unit 1B,
132, Weyhill Road, Andover,
Hampshire, SP10 3BE

01256 893 517
01264 313 999

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Dental CT Scan Request Form

Patient Details

Fields marked with * are compulsory and must be filled in.

Referring Dentist (IRMER referrer)

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) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes) *

Step 2. Scan Details

Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications. *
In accordance with IR(ME)R 2000 a clinical justification must be provided for each CT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CT scans.
Images will be reviewed and findings recorded by an IRMER operator (reporter). *

Step 3. Costs


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