CBCT/Imaging Referral Form

High-quality Dental Care in Lincoln

West Parade Dental welcomes referrals and is committed to co-managing your patient’s oral healthcare. The first step is to fill out our digital CBCT referral form, or call us on 01522 523 821 to discuss your case.

Thank you for choosing West Parade Dental Care to carry out your patient’s scan. It is a requirement that you fill out an initial service level agreement form for us to document in our record of referring dentists. This is the latest best practice standard and in accordance with guidance issued by the European Commission. By completing the form you are confirming:

  • That you are referring in accordance with the published guidance criteria (sedentext.eu)
  • That you have fulfilled the standard education requirements for the use of ionising radiation and radiation protection.
  • You can provide certification of further training for CBCT Referrers/Reporting

Please return the following signed service level agreement together with any copies of supporting CPD training evidence.

Download service level agreement

Download printable CBCT referral form

Fees Payable:

OPT
£45
CBCT 50 mm x 50 mm
£120
CBCT 100 mm x 85 mm
£150

If reporting is required, a further fee is payable in addition to the above:

50 mm x 50 mm
£65
100 mm x 85 mm
£140

Digital CBCT/Imaging Referral Form

To refer your patient for treatment at West Parade Dental simply complete our secure digital referral form below, we’ll do the rest!

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