External Referral Please select your option Please select the type of treatment from above Download Offline Form Type: Referrer Details Name of Referrer*: Practice Name*: Email*: Telephone*: Address*: Patient Details Name of Patient*: Date of Birth*: Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Address*: Telephone*: CLINICAL INDICATIONS (Please Complete)* : JUSTIFICATION FOR X-RAYS* Digital Panoramic Implants Bone Graft Impacted Teeth Endodontics Sinus Exam TMJ Oral Pathology Ortho Mandible Maxilla Both Jaws Is the patient coming with Radiographic Stent*: Yes No Is the patient possibly pregnant?*: Yes No PAYMENT BY*: Referrer Patient COST: CBCT Single Arch £150, CBCT Both Arches £300, iTero Scan both Arches £150 Please select your preferred CBCT format*: DICOM CT VIEWER iTERO SCAN File delivery options*: To Patient To Referrer Dropbox Email USB Stick WeTransfer Note: Bluebell Dental Practice and Clinic do not routinely report on CBCT scans. To comply with the IRMER 2000 regulations all CBCT scans are required to be reviewed and reported in the clinical notes by the referring practitioner or by a radiologist. Please select the type of treatment from above Download Offline Form Type: Doctor information: Name *: Address *: Telephone *: Email *: Patient information: Name *: Date of Birth *: Date 12345678910111213141516171819202122232425262728293031 Month 123456789101112 Year 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Address *: Telephone *: Home: Work: Mobile: Reasons for referral *: Relevant Medical History *: Service required *: Opinion only Opinion & treatment Attach radiographic file *: (Please attach as a image(jpeg,jpg format), file size no greater than 1MB)
