Smile Style
Dental Care Centre

Dentistry With You in Mind

CBCT Referral

We welcome your CBCT Scan and OPG referrals to Smile Style Dental in Stafford. If you are referring using the online form, please fill out the Radiography Service Level Agreement and attach it to the form.

Download Service Level Agreement

Referring is Easy

Please Complete The Form Below

Referring Dentist Name *

Referring Dentist Number *

Referring Dentist Email Address *

Referring Dentist Address *

Patient Title *

Patient Name *

Date of Birth *

Patient Email Address *

Patient Number *

Patient Address *

Clinical context for requesting a dental CBCT examination *

Relevant results of history, clinical examination and other imaging *

What information would you like the dental CBCT to provide? *

Define the anatomical area that the scan(s) should cover *

If you would like to attach radiographs, clinical notes, and evidence of level 1 CBCT training, please use the upload facility below. Accepted formats: JPG, JPEG, PNG only (maximum 1 file, 2 MB per upload box).

Click or drag a file to this area to upload.

Choose File

Click or drag a file to this area to upload.

Choose File

Click or drag a file to this area to upload.

Choose File

Click or drag a file to this area to upload.

Choose File

Reporting of Scans *

I fully understand that Smile Style Dental does not report on the scans and radiographs requested by referring GDP’s, unless specifically requested to do so (at an extra cost to the patient).

I am the IR(ME)R referrer/operator. I am adequately trained to report on my patients scan.

Dentist Declaration *

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.

These guidelines are available on:https://assets.publishing.service.gov.uk/media/5a7d4f13ed915d321c2de451/HPA-CRCE-010_for_website.pdf

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Where To Find Us

Smile Style Dental Care Centre

Address

Smile Style Dental Care Centre,
24 Lichfield Road,
Stafford,
ST17 4LL

Contact

Call: 01785 225505

WhatsApp: 07752522333

Email: Click Here

Opening Hours

Monday: 8.00am – 5.00pm
Tuesday: 8.00am – 6.30pm
Wednesday: 8.00am – 5.00pm
Thursday: 8.00am – 6.30pm
Friday: 8.00am – 5.00pm
Saturday: By Appointment

Get In Touch

Ask A Question

For any questions or queries, please drop us a message using the contact form below and a member of our friendly reception team will get back to you as soon as possible.