Referral Form DENTIST REFERRAL FORM FOR CT SCANS AND OPT 1 Referral Type2 Dentist Details3 Patient Details Justification for scanArea to be scannedScan Required Digital OPT Small Field CT Scan Lower Jaw CT Scan Upper Jaw CT Scan Upper and Lower Jaw CT Additional Copies of CD Scan Required*Please chooseDigital OPTSmall Field CT ScanLower Jaw CT ScanUpper Jaw CT ScanUpper and Lower Jaw CTAdditional Copies of CDCommentsAdditional information* I will make my own reporting arrangementsTo comply with the IRMER 2017 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. Park Dental Care strongly recommends that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. Dentist DetailsTitleDrMrMrsMsDentist Name First Last Date of Referral Date Format: MM slash DD slash YYYY Postcode*TelephoneMobileEmail Patient DetailsTitleDrMrMrsMsPatient Name GDC NoGenderPlease select oneMaleFemaleDate of Birth Date Format: MM slash DD slash YYYY Address* Street Address City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone*Mobile*Email Relevant Medical Details*Short summary of case* Park Dental Care aim at assisting professionals and patients in diagnosis and treatment planning. Park Dental Care is not providing and is not responsible for providing any interpretation of images or clinical service such as diagnosis or treatment. Park Dental Care endeavours to provide the very highest quality results, however Park Dental Care will not accept any liability for incorrect or incomplete information on the referral form or inappropriate or inadequate patient preparation which may compromise the value of the final results. By referring a patient, the referring practitioner agrees to the terms of the Park Dental Care standard Service Level Agreement. Park Dental Care endeavours to despatch the images to the referrer and/or the patient as quickly as possible, however e.g. equipment malfunction may introduce delays. Park Dental Care reserves the right not to accept referrals in such cases. Park Dental Care must be notified 24 hours in advance of the patient’s visit to the imaging centre if a particular urgent service is required.