Dental CT Scan Request Form

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Patient Details
Referring Dentist's Details

I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes)

Confirm Irmer Referrer Training*

Scan Details

  • Region to be Scanned*

  • Patient to wear stent provided by dentist ?*

  • Due to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications.*

  • 2nd scan, of stent, required ?*


In accordance with IR(ME)R 2000 a clinical justification must be provided for each CT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CT scans.

Images will be reviewed and findings recorded by an IRMER operator (reporter).


Treatment Costs*

Do you have any files you wish to attach in support of this referral?*


Please tick the supporting material you will be posting us


File Attachment


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