OPG CBCT Referral – Lovat House Dental

Name
This field is for validation purposes and should be left unchanged.
- CBCT referrals will be accepted from clinicians who have signed the Lovat House Dental CBCT Service Level Agreement and provided evidence of their training for CBCT appropriate referral (Level 1 and above). To request a copy of this agreement, please email clinical@lovathousedental.co.uk
  
  The default position is that the referring practitioner reports the scan or sources a CBCT report. Please state if you wish for us to source and generate a CBCT report for you.
- Is a CBCT report required(Required)
  - Yes
  - No
- Patient Details
- Name(Required)
  Title First Name Surname
- Patient Date of Birth(Required)
  
  Day
  Month
  Year
- Patient Address(Required)
- Patient Postcode(Required)
- Patient Phone Number(Required)
- Patient Email(Required)
- Referring Dentist
- Dentist Name(Required)
- Dentist Telephone(Required)
- Practice Address(Required)
- Dentist Email(Required)
- Practice Postcode(Required)
- Referral Details
- Medical History(Required)
- Possibility of pregnancy(Required)
  - Yes
  - No
- Service Required(Required)
  - OPG
  - CBCT
- Region of Interest(Required)
  - Small Volume 5cm x 5cm scan
  - Single jaw 8cm wide, 5cm height scan
  - Both jaws 8cm x 8cm scan
- Small Volume 5cmX5cm(Required)
  - Upper Left
  - Upper Right
  - Lower Left
  - Lower Right
  - Lower Anterior
  - Upper Anterior
- Single jaw 8cm wide, 5cm height scan(Required)
  - Upper Teeth/Jaw
  - Lower Teeth/Jaw
- Reason for referral and justification for CBCT Scan(Required)
- Benefit to the patient/ Previous Imaging(Required)
- Structures to be imaged(Required)
- IR(ME)R Regulations: To comply, all radiographs must be clinically evaluated to rule out the possibility of coincidental pathology. We do not routinely report on CBCTs or OPGs or X-rays; by referring for dental imaging, the referrer accepts the responsibility for arranging reporting. Alternatively, we can offer a radiographic report on request. If your patient requests a report, this will need to be provided by the referrer.
  
  The scan/ DICOM data will be sent via Special Delivery on password protected USB Stick to the referrer's address. The USB stick also contains CBCT viewing software. OPG .jpg images can be emailed with patient consent
- Do you have additional files to upload in support of this referral?
  - Yes
  - No
- File Attachments
  Drop files here or
  
  Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 512 MB.
- Signature

OPG / CBCT Referral

Patient Details

Referring Dentist

Referral Details

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