Patient Details Fields marked with * are compulsory and must be filled in. Patient Name* Patient Address* Patient Postcode* Patient Telephone* Patient Date of Birth* Patient Doctor/GP * Referring Dentist (IRMER referrer) Referrer Name * Referrer Email * Referrer Address* Referrer Telephone* Referrer GDC Number* 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) * Please Confirm Yes No Step 2. Scan Details Region to be Scanned * Please Select Maxillae Mandible Both Patient to wear stent provided by dentist ? * Please Select Yes No 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. * Please Confirm Patient Competent 2nd scan, of stent, required ? * Please Select Yes No 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. Reason for Referral and Justification for the scan * Special Instructions to IRMER operator involved in scan acquisition: * Images will be reviewed and findings recorded by an IRMER operator (reporter). * Step 3. Costs Dental CT Scan for single tooth or jaw : £175 Dental CT Scan for both jaws : £250 Second scan of stent for "Nobelguide" or similar : £50 This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.