FOR RADIOGRAPHER USE: Room: Rad: Int: Ext: Occ: Slot No’s Dental Hospital Radiology request form Affix patient I.D. label or complete details: – Request for: Surname: MRN: Dental Imaging only Forename: NHS No: * Address: DOB Imaging and Report - see sections below Report only Mounting of radiographs Postcode: Gender: Patient category: Requested dental images (use Palmer notation): Hospital NHS Practice Private Patient pathway For CBCT please state: large/small volume. High res / standard / low dose and area of interest and tick the declaration below. Please tick Referrals for Cone Beam CT imaging from external sites- it is assumed that Patient can leave after referrers have undertaken Level 1 CBCT training, and that any clinician acting as x-ray IR(ME)R Operator /Reporter has undertaken Level 2 CBCT training. Patient to return to By referring for the above CBCT I confirm that I am in compliance with the above department (please tick) Relevant clinical information and justification for imaging: Pregnant : Yes / No / n/a * Relevant previous imaging (including dates) : * Images to be reported (including dates) : * Clinical question to be answered in report : Requesting clinician name / grade: Signature: Date: Consultant: Referring department: Department contact number: For office use only Date Received: Appointment Requested: Date: Date Vetted: Time: INCOMPLETE FORMS WILL BE RETURNED
Dental Hospital – Radiology request form Affix patient I.D. label or complete details: Request for: Surname: MRN: Dental Imaging only Forename: NHS No: Imaging and Report - see sections below * Address: DOB Report only Mounting of radiographs Postcode: Gender: Patient category: Requested dental images (use Palmer notation): Hospital NHS Practice Private Patient pathway Please tick For CBCT please state: large/small volume. High res / standard / low dose and area of interest and tick the declaration below. Referrals for Cone Beam CT imaging from external sites- it is assumed that referrers have undertaken Level 1 CBCT training, and that any clinician acting as IR(ME)R Operator /Reporter has undertaken Level 2 CBCT training. By referring for the above CBCT I confirm that I am in compliance with the above (please tick) Patient can leave after x-ray Patient to return to department Relevant clinical information and justification for imaging: Pregnant : Yes / No / n/a Relevant previous imaging (including dates) * : Images to be reported (including dates) * : Clinical question to be answered in report * : Requesting clinician name / grade: Signature: Date: Consultant: Referring department: Department contact number: For office use only Date Received: Appointment Requested: Date: Date Vetted: Time: FOR RADIOGRAPHER USE: Room: Rad: Int: Ext: Occ: Slot No’s INCOMPLETE FORMS WILL BE RETURNED