CBCT Referral for Vitality Stokesley

We welcome referrals from the dental community with convenient access to a team of dental services including: Endodontics, CT Scans, Perio, Ortho and Implants.

Collectively, we offer a patient-focused, multi-disciplinary approach to complex dental problems with the aim of achieving the best possible outcome for your patient.

Vitality Stokesley 21 High Street, Stokesley TS9 5AD

01642 712 519

vitalityreception@riverdalehealthcare.com

CBCT Form

Please fill in this multi-part form below with as much detail as possible.

Fields marked with an * are required.

Title

Patient Name

Patient Address

Postcode

Date of Birth

Tel: Home Phone

Tel: Work Phone

Tel: Mobile Phone

Patient Email

Preferred method of contact

Dentist Name

Dental Practice

Practice Address

Postcode

Phone Number

Brief Patient History:

Reason for Scan:

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque to be worn?

Yes No

Field of view (CBT Scan Charges):

Small Field (50X50mm) £103.00 Full Upper (80X50mm) £242.00 Full Lower (80X50mm) £242.00 Dual Jaw (80X90mm) £330.00

Dentist Signature

Dentist GDC Number

STANDARD IMAGE RESOLUTION WILL BE SUPPLIED UNLESS YOU SPECIFICALLY REQUEST HIGH RESOLUTION OR ENDO (80X50mm FOV only)

Reports: Indicate your preference for radiological interpretation of the dento-alveolar region:

I undertake to report on the scan required by IR(ME)R 2000/2006

I accept

Assistance with planning:
Assistance with case planning at Vitality Dental Care: Price on application.
YOUR PATIENT WILL BE ASKED TO PAY FOR THEIR SCAN AT THEIR APPOINTMENT.

Vitality Stokesley

21 High Street,
Stokesley,
TS9 5AD

CBCT Referral for Vitality Stokesley

CBCT Form

Vitality Stokesley

01642 712 519

Out of hours – call practice number above

vitalityreception@riverdalehealthcare.com

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