Dental Imaging Referral

Safe, fast, state-of-the-art dental imaging

Norfolk Dental Specialists is one of the few dental practices in East Anglia with its own 3D Cone Beam CT scanner. We offer the most advanced independent scanning centre and service available in the area, and welcome referrals from any local dentists who would like a CBCT scan of a patient.

Download form

Saved form code

Retrieve saved form

Patient Details

Patient First Name*

Patient Last Name*

Patient Address Line 1*

Patient Address Line 2

Town/City*

Postcode*

Patient Date of Birth*

Patient Contact Telephone*

Patient Email Address*

Referral Details

Clinical Context for requesting scan, including justification*

How would you like to receive the CBCT scan? Dicom Files (raw data) USB (includes CD Viewer)

What information do you want the dental CBCT examination to provide?*

Volume of Scan (Please choose)* 2D DPT 3D 5X8 (Full Arch)

Please select one the below options*

Upper Only Lower Only Upper & Lower

Reporting of Scans (Please tick which of the following applies to you)*

I am the IRMER referrer only. I wish NDS radiologist to provide me with a report on my patient’s scan. I have advised my patient that the fee will be £150 per report in addition to the scan fee. I am the IRMER referrer / operator. I am adequately trained to report on my patient’s scan.

Please inform us what area to scan

Referring Dentist Details

Dentist First Name*

Dentist Last Name*

Dentist GDC Number

Dentist's Contact Telephone

Dental Practice Email Address*

Practice Name

Practice Address Line 1

Practice Address Line 2

Town/City

Postcode

Saved forms will be held for 7 days. Images and checkbox options cannot be saved and must be re-uploaded and re-checked.