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CBCT Scanning Referral
Maisie
2021-12-29T15:13:09+00:00
cbct scanning refferal default text to be added in..
More default Paragraph text ref cbct form
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Date of Examination
*
Referred by Name
*
First
Last
Referred by Address
*
Town/City
*
County
*
Postcode
*
Referred by Phone Number
*
Referred by Email Address
*
Referred by GDC Number
*
Patient Title
*
Patient Name
*
First
Last
Patient Contact Number
*
Patient Email Address
*
Patient Address
*
Address Line 2
Town/City (copy)
*
County (copy)
*
Postcode (copy)
*
Patient Date of Birth
*
Possibility of Pregnancy
*
Yes
No
Patient relevant medical history
*
Payment
*
Account to referrer
Patient to pay
Examination Required
*
Digital Panoramic
Cone Beam CT Parallel to Occlusal Plane / Lower Border / Palate
My patient will wear a stent?
*
Yes
No
UR
1
2
3
4
5
6
7
8
UL
1
2
3
4
5
6
7
8
LR
1
2
3
4
5
6
7
8
LL
1
2
3
4
5
6
7
8
Region of Interest
*
Upper Jaw
Lower Jaw
Small Fov (Please detail area of interest below. Please also use the tooth diagram above when appropriate)
Reason (E.G. Implant planning)
*
Justification
*
Software Options for Cone Beam CT Scans
*
CT Viewer
DICOM
Please contact me to discuss options
Delivery Options
*
CD (Patient)
Online Data Transfer
Notes
Sign Off
I would like this patient’s radiographic examination to be reported upon by your Consultant
I will make my own reporting arrangements
Checkboxes
First Choice
Second Choice
Third Choice
Submit
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