Secure CBCT/OPG Referral Form For information about how we will use your personal details please see our Privacy NoticePatient DetailsTitle*MrMrsMissMsDrOtherDate of Birth* Day Month Year Name* Tel (Home) AddressTel (Work) Postcode* Tel (Mobile) Referring PractitionerDentist Name* Practice Name* Practice Address*Dentist Email* Practice Postcode* Practice Phone Number Referral DetailsMedical HistoryReason for referral and justification for CBCT Scan/OPTExamination Request for Dental CBCTPlease select area(s) for CBCT scan* Maxilla Mandible Both Small volume CBCT to include up to 3 teeth Imaging stent provided Yes No Image Management for Digital OPT OPT on photographic paper OPT on CD OPT as email attachment Image Management for Dental CBCT CBCT Scan on CD CBCT Scan emailed Do you have additional files to send in support of this referral? Yes No How will you be sending attachments? By email Attached to this form By post File Attachments Drop files here or Select files Accepted file types: jpg, pdf, doc, docx, Max. file size: 64 MB. Patient is aware of fee payable on the day to Ikon Dental Suite*Fees are £120 full jaw(maxilla or mandible) £65 OPG and £95 small volume scan.” Yes, patient is aware Cost of radiology report*Please be aware, if you requires a radiology report for this referral, there is a fee of £85. Yes, I am aware Ikon Dental Suite does not routinely report on CBCT scan. To comply with the IR(ME)R 2000 regulations all CBCT scans are required to be reviewed and reported in the clinical notes by the referring practitioner or by a radiologist.* Please tick to acknowledge EmailThis field is for validation purposes and should be left unchanged. This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.