17 Dental Logo

CBCT Referral Form

  • Home -
  • CBCT Referral Form

    CBCT Form

    Practice information

    Patient information

    3-D CBCT area of interest

    Please tell us why you are requesting a CBCT

    Referrer declaration

    I hereby authorise 17 Dental to perform a 3-D CBCT scan on my patient. If a scanning guide is required I will ensure it is prepared in advance and provided to the patient to bring to their appointment. Scan results will be delivered either by USB with compatible viewing software or securely uploaded through Dropbox Business. A basic review of the scan may be conducted. I acknowledge that I am solely responsible for interpreting the data and making any necessary clinical referrals. I understand that 17 Dental and its operators are not responsible for determining treatment suitability or identifying any pathology. I accept full responsibility for evaluating the scan and acting upon any findings. In accordance with the HPA CRCE-010 guidelines, I recognise that completion of a CBCT training certificate course is a mandatory requirement for all professionals involved in CBCT imaging, including those referring patients. I accept the responsibility to obtain the necessary qualifications to interpret the scan data provided; alternatively I will arrange for a consultant radiologist or another suitably qualified individual to assess the scan for any incidental findings.

    Please confirm that you are certified to request a CBCT.