Secure CBCT Scan/OPT Referral Form

For information about how we will use your personal details please see our Privacy Notice
Patient's Details
Patient's First Name*
Patient's Surname*
Patient's Address*
Patient's Postcode*
Patient's Email
Patient's Date of Birth*
DD slash MM slash YYYY
Patient's Home Phone Number
Patient's Mobile Number
Referring Dentist's Details
Dentist's Name*
Dentist's Phone Number*
Practice Address*
Practice Postcode*
Referring Dentist's Email Address*
Referral Details
Reason for referral and justification for CBCT Scan/OPT*
Relevant Medical History*
Examination Request for Dental CBCT
Please select area(s) for CBCT scan*
Imaging stent provided*
Image Management for Digital OPT
- OPT on photographic paper
- OPT on CD
- OPT as email attachment
Image Management for Dental CBCT
- CBCT Scan on CD
Reporting
CAPI Ltd does not routinely report upon scans and radiographs. To comply with the IRMER 2017 regulations all radiographs and scans are required to be reviewed and reported on the clinical notes by the referring practitioner or by a radiologist. CAPI Ltd strongly recommends that all CBCT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. CAPI Ltd offers a reporting service by a Consultant Radiologist.
Reporting Choice
- I would like this patient's radiographic examination to be reported upon by your Consultant Radiologist (£90-£150)
- I will make my own reporting arrangements
Do you have any files you wish to attach in support of this referral?*
- Yes
- No
File Attachment
Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.

This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.

Dentist in Kent

Patient's Details

Referring Dentist's Details

Referral Details

Examination Request for Dental CBCT

Reporting

You are now in a secure area