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80 Salisbury Street, Blandford Forum, Dorset, DT11 7PS
01258 452091
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About
About Us
Meet the Team
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Dental Check-ups
Emergencies
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Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
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Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
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Facial Rejuvenation
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Book now
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
Dentist Referral
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
Book now
Dentist Referral
Dentist Referral
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
About
About Us
Meet the Team
Fees & Finance
Dental Blog
New Patients
Dental Check-ups
Emergencies
Membership Plan
General
Dental Check-ups
Emergencies
Dental Bridges
Dentures
Crowns
Root Canal Treatment
White Fillings
Tooth Extraction
Children’s Dental Health
Cosmetic
Veneers
Teeth Whitening
Composite Bonding
Teeth Straightening
Invisalign®
Aligners
Clear Braces
Implants
Hygienist
Facial Rejuvenation
Contact
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CT Scan / OPG Referral
First Name
Last Name
Email
Telephone
Date of Birth
Patient Address
Name of Dentist
Dentist’s Phone Number
Practice Postcode
Referring Dentist Email Address
Referrer GDC Number
Practice Address
Confirm Irmer Referrer Training *
Confirm Irmer Referrer Training *
Yes
Region to be Scanned *
Region to be Scanned
Maxillae
Mandible
Both
Other
Patient to wear stent provided by dentist ? *
Patient to wear stent provided by dentist ? *
Yes
No
Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications. *
Yes, patient is competent
Yes, patient is competent
2nd scan, of stent, required ? *
2nd scan, of stent, required ? *
Yes
No
Reason for Referral and Justification for the scan
Special Instructions to IRMER operator involved in scan acquisition
Confirm image only *
Confirm image only *
Yes
No
Radiologist report needed *
Radiologist report needed
Yes
No
Treatment Costs *
Treatment Costs *
Dental CT Scan for single tooth or jaw : £99
Dental CT Scan for both jaws : £150
Second scan of stent for “Nobelguide” or similar : £50
Radiologist report, where requested, shall be quoted separately.
NOTE
: CT-Scan files will be given to the patient on a CD with the required viewing software.
Acceptance *
I consent to my data being used in accordance to the Privacy Policy.
I consent to my data being used in accordance to the
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CT Scan / OPG Referral
Patient Referral
CT Scan / OPG Referral
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