For the referral of patients for Dental CBCT & Panoramic Radiography examinations

Patient Name *

First

Last

Patient Telephone Number *

Patient Address

Patient date of birth (DOB)

Relevant medical history:

Other relevant information & brief treatment history:

Has the patient been informed of the cost of the scan

• Yes
• No

If not, is this because the practice is paying for the scan?

• Yes
• No

Xrays uploaded (will be uploader on live site)

Referring Dentist Name *

Referring Dentist Email *

Referring Dentist Practice Telephone Number *

Referring Practice Address

Date of Referral

I am the IRMER referrer & operator. I am adequately trained to report on my patients scan

• Yes
• No

Type of radiographPanoramic (OPG)Dental CBCT

Clinical context for requesting the above examination:

Relevant results of history, clinical examination and other imaging:

What information do you want the radiographic examination to provide?

Define the anatomical area that the radiograph should cover:

Intra-oral scans/clinical photos

Click or drag files to this area to upload. You can upload up to 5 files.

Maximum file size 3MB per file

Submit