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Dental CT Scan and OPT Referral Form

Patient Details








Referring Dentist Details






Treatment Details



Radiographs






Dicom files for the scan together with diagnostic and planning software will be delivered to the referring dentist on CD.

Moss Osman of Bridge Dental Clinic does not report upon scans and radiographs on behalf of referring dentists. To comply with the IRMER 20000 regulations all radiographs and scans are required to be reviewed and reported into the clinic notes by the referring practitioner or by a radiologist. We strongly recommend that all CT and other radiograpih examinstaions should be reported upon to rule out the possiblility of coincidental pathology.

Moss Osman of Bridge Dental Clinic offers a reporting service by a Consultant Radiologist (Please tick below).


Payment

If you would prefer, you can download a PDF version of this form. You can email scan and email this to us, or post it to us.