CBCT Scan Referral - Montgomery Dental Care

CBCT Scan Request

To refer a patient to Montgomery Dental for a CBCT scan, please complete and submit the referral form below.

Kindly provide all relevant clinical details relating to the patient’s case to help us assess the referral appropriately.

Once we receive the referral, our team will contact the patient directly to introduce the practice and arrange a suitable appointment. We will also keep you informed throughout the patient journey. Please note that CBCT scan reporting is not included as standard but can be provided upon request.

Scan CBCT details / Region of interest

Is the patient attending with a radiographic template?

Yes No

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

Confirm shape of residual alveolus Confirm descent of nasal / maxillary sinus prior to implant placement Confirm position of mandibular canal / mental foramen prior to implant placement Assess impacted teeth Endodontic planning - please define primary area of interest

Special Instructions to IRMER operator involved in scan acquisition

The requested CBCT scan is to be reported by referring clinician. Would you prefer the scan to be reported by a Consultant maxillofacial radiologist? (Additional fee of £85)*

Yes No

Payment: Who is responsible for payment?

Patient at appointment Invoice referring practitioner

I confirm that the patient has given consent to be contacted by Montgomery Dental Care

Via telephone Via telephone & letter Via telephone, letter & email

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Montgomery Dental Care

Yes No

Acceptance
By submitting this referral, I authorise Montgomery Dental to undertake an OPG scan on behalf of my patient. The completed OPG image will be provided electronically via secure email.

I acknowledge that responsibility for reviewing, interpreting, and acting upon the radiographic findings remains solely with the referring clinician. This includes:

Assessing the suitability of treatment
Identifying any abnormalities or pathology
Arranging onward referral to the appropriate specialist services where clinically indicated

Montgomery Dental and the radiographic operator are not responsible for diagnosis, treatment planning, reporting, or referral decisions arising from the scan.

I understand that current radiography guidance recommends that all clinicians referring patients for OPG imaging hold appropriate radiology training and competency.

By making this referral, I confirm that:

I have the necessary qualifications, training, and experience to evaluate the radiographic information provided; or
I will arrange assessment and reporting by a suitably qualified Consultant Radiologist where appropriate.

Service Level Agreement: The service level agreement for our CBCT scanning service ensures compliance with best practice guidance. This necessary agreement will allow you to refer your patients for CBCT scans with appropriate justification. This simply requires you and your colleagues at your practice to:

Confirm that you refer in accordance with published guidance criteria confirm that you have fulfilled the standard education requirements in the use of ionising radiation and radiation protection and provide certification to show that you have undertaken additional training for CBCT Referrers please read new certification requirements above in red.

Please complete and return your agreement along with copies of your relevant CPD certificates as soon as practicable so that you can start to refer patients for scans. Please also complete and return a patient CBCT referral form outlining all of your requirements. In accordance with guidance issued by the European Commission, we have adopted the best practice which requires dentists who refer patients for CBCT scanning to have a service level agreement in place with their chosen CBCT scanning referral centre. As per the published dental guidance notes, recommended ‘adequate training’ standard for dental practice staff referring for dental CBCT scans is to complete Level 1 (Core) training in dental CBCT. We accept referrals with evidence of adequate scan referral training as the guidance notes state that completion of Level Core training in dental CBCT is only the latest recommended adequate training. Therefore you can continue to refer to us for scans using your previous qualification with the choice of updating your training if you wish to refresh your knowledge. (All of our clinicians have completed Level 1 and 2 and continue to refer and report on scans).

CBCT Scan Request

MONTGOMERY DENTAL CARE

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