Scan requests can be done one of two ways. 

1. Download our form, print and submit to our office via email or post.

or

2. Fill out the form below and submit it directly to our office.

Dental CT Scan Request Form PDF (right-click to download)

Online Dental CT Scan Request Form
  • Patient Details
    0
  • Title*
    1
  • Initials*
    2
  • D.O.B.*
    3
  • First Name*
    4
  • Surname*
    5
  • Address*
    6
  • Home Tel*
    7
  • Work Tel*
    8
  • Mobile Tel*
    9
  • Notes*
    10

  • Referring Dentist Details
    11
  • Dentist Name*
    12
  • Dentist Email*a valid email address
    13
  • Name*full name
    14
  • Practice Tel*
    15
  • Practice Address*something more
    16
  • Reason for scan and justification*
    17
  • By signing this, I undertake to report on the scan as required by IR(ME)R 2000/2008:
    18
  • Dentist Signature*
    19
  • GDC Number*
    20

  • CT Scan Requirements
    21
  • All scans will be parallel to the occlusal plane unless otherwise specified. Scans are on CD.
    22
  • Radio-opaque markers to be worn?
    23
  • Radio-opaque markers to be worn?*
    Yes
    No
    24
  • Maxilla or Mandible?*select one or more
    Maxilla
    Mandible
    25
  • Full or Small Arch?*select one or more
    Full Arch (FOV 6 x 8 cm)
    Small Arch (FOV 6 x 4 cm)
    26
  • Centre around which area?*
    27
  • Copy the letters to reduce spam
    28
  • 29