Dental CBCT Scan Referral Form

Practice Providing CBCT Address Phone Email

1. Patient Details Patient Full Name Date of Birth Patient ID / Chart Number (if applicable)

2. Referring Dentist Details Referring Dentist Name Practice Name Practice Address

Telephone Email

GDC Number Date of Referral

3. Type of CBCT Scan Requested

Please tick the appropriate option:

Sectional CBCT Scan If sectional scan, specify area or tooth/teeth Tooth Number(s) / Region

Clinical Area (tick if applicable):

Upper Right Upper Left Lower Right Lower Left

Anterior Maxilla Anterior Mandible

Full Maxillary CBCT Scan Full Mandibular CBCT Scan

4. Clinical Indication / Justification for CBCT (IR(ME)R)

Examples: Implant assessment, impacted tooth localisation, endodontic assessment, pathology investigation, surgical planning.

5. Additional Clinical Information (Optional)

Previous radiographs taken?

Yes No Relevant clinical findings

6. Reporting Requirements Scan only (referring dentist will interpret) Radiology report requested

7. For Imaging Centre Use Only Date Scan Performed Operator Exposure Settings / FOV Report Completed By

Professional dental care in Glasgow's West End. We believe every patient deserves to be truly heard and understood.

West Dental
2 Lansdowne Cres
Glasgow's West End
G20 6NQ

Opening Hours:
Mon-Fri: 9:00am - 5:00pm

Book your consultation or speak to our team today

Last Updated: March 2026