CBCT Referral Form - Pristine Dental Group

Pristine Dental Group

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Straightening
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- CBCT Referral Form
- Patient Referral form

Implants
Pricing
Referrals
- CBCT Referral Form
- Patient Referral form

Precision Imaging You Can Trust

Fill in the secure CBCT (Cone Beam Computed Tomography) REFERRAL FORM below.
Our team will get in touch with your patient promptly and keep you informed throughout their treatment journey.

State-of-the-art CBCT technology for crystal-clear images
Low-dose, patient-friendly scans in a relaxed environment

Fast turnaround with secure digital delivery
You remain the lead clinician. We simply assist

Referring Dentist Details

Please provide details of the referring dentist below.

Dentist First Name *

Dentist Surname *

Contact Number *

Email Address *

Patient Details

Please provide as much detail about the patient below.

Preferred Title *

Date of Birth *

First Name *

Surname *

Contact Number *

Email Address *

Patient’s Gender *
MaleFemale

Payment Type *
DoctorPatient

Earliest date to scan the patient *

Referral Details

The Radiographer will take a scan with the lowest dose, smallest field of view and best resolution, according to the area of interest and clinical indications, in line with IRMER and ALARA. The age, anatomy and physical build of the patient are all dependent factors.

Please select which services you require for this patient: *
CBCT Scans2D Imaging

Teeth Chart

Please indicate teeth and areas of interest. If none are selected, the whole jaw will be scanned.

Upper Left

UL1UL2UL3UL4UL5UL6UL7UL8

Upper Right

UR1UR2UR3UR4UR5UR6UR7UR8

Lower Left

LL1LL2LL3LL4LL5LL6LL7LL8

Lower Right

LR1LR2LR3LR4LR5LR6LR7LR8

CBCT Information

Please indicate details of CBCT scan requirements below.

Is the patient coming with a radiographic template? *
YesNo

Clinical Indications *

CBCT Area of Interest *
SectionalQuadrantMandible (Lower Jaw)Maxilla (Upper Jaw)Both JawsBoth Jaws (Orthodontics)

Do you require a CBCT report? *
YesNo

Does reduction technology required? *
YesNo

Justification for X-ray (multiple choice): *
ImplantsEndodonticsSinus LiftBone GraftRamus Bone GraftOrthodonticsOral PathologyTMJPeriodonticsChin Bone GraftImpacted TeethSinus ExamZygomatic ImplantsAirway Study

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RISK DISCLAIMER

Composite bonding is a safe, non-invasive cosmetic procedure designed to enhance the appearance of your teeth. However, like any dental treatment, it comes with potential limitations and risks.
*Bonded materials may stain over time, especially with frequent consumption of tea, coffee, or red wine. They are also not as strong as natural teeth or porcelain veneers and can chip or wear down with heavy biting or grinding. Results can last several years with proper care, but maintenance or touch-ups may be needed. A full consultation will help determine if composite bonding is the right option for your individual case.
*Always follow your dentist’s aftercare advice to maximise longevity and minimise potential risks.

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