Ct Scan Referral Form Template For Practitioners - Igdp

CT   S can   R eferral   F orm   f or   P ractitioners

 

 

Email   t o:   i nfo@igdp.co.uk  

Fax:   0 20   7 704   1 057  

Complete   O nline:   i gdp.co.uk/ct-­‐scan-­‐referral-­‐form  

 

 

Patient   D etails  

 

( Please   p rovide   a ll   i nformation)

Title   &   S urname:  

DOB:  

First   N ames:  

Address:  

 

Postcode:  

Tel:  

Mob:  

Email:  

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Pregnancy:       Y es/Possibly  

      N o  

    N ot   r elevant  

 

Any   r elevant   m edical   c onditions:  

 

Referring   D entist   D etails  

 

( Please   p rovide   a ll   i nformation)

Name   &   S urname:  

Practice   N ame   &   A ddress:  

 

Postcode:  

Tel:  

Email:  

 

Details   o f   S can   R equired  

 

( Please   p rovide   a ll   i nformation)

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Payment:                 P atient  

    R eferrer  

 

Is   t he   p atient   c oming   i n   w ith   a   r adiographic   t emplate:           Y es  

    N o  

 

 

Area   o f   C oncern:  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Scan   R equired:  

 

Clinical   I ndication   f or   S can:  

 

( Please   S elect)

( Required)

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-­‐£50  

Digital   O PG  

 

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-­‐£120  

Small   F ield   C T   S can  

 

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-­‐£120  

U/L   J aw   C t   S can   5 x8cm  

 

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-­‐£120  

U   &   L   J aw   C t   S can   8 x8cm  

 

 

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Output:  

    E mail  

    P hoto   P aper  

      C D  

   

( Please   S elect)

( CBCT   S can   w ill   c ome   w ith   o ne   C D   a nd   V iewing   S oftware)  

 

 

 

 

Referrer   S ignature  

 

Date  

 

 

 

 

 

Thank   y ou   f or   t he   r eferral.     P lease   d o   n ot   h esitate   t o   c ontact   u s   i f   y ou   n eed   h elp   c ompleting   t he   f orm.     Y ou   c an   c ontact  

us   o n   0 20   7 226   0 849   o r   e mail   u s   a t   i nfo@igdp.co.uk