Endodontic Referrals | Trusted Dental Treatment Solutions

Endodontic
Referrals

1. Dentist's Name

2. Dentist’s Contact Number

3. Dentist's secure email address

4. Patient's Name

5. Patient's Date of Birth

6. Patient's Contact Number

7. Justification for image requested

8. Type of Scan Required

9. Information required and anatomical area(s) the scan should cover

10. Anything we should be aware of relating to the patient's care?

11. IRMER Legislation Acknowledgement

By ticking this box, I acknowledge that I am aware of my responsibilities under the Ionising Radiation (Medical Exposure) Regulations (IRMER) legislation and that the images will not be reported on by the imaging centre and that it is assumed that referrers have undertaken Level 1 CBCT training, and that any clinician acting as IRMER Reporter has undertaken Level 2 CBCT training

I acknowledge