CBCT Referral In Kuala Lumpur

Please fill up the Referral Form

Referring Dentist Details

Referring Dentist* Practice Name* Practice Address 1* Practice Address 2 Practice Postcode* Practice Phone Number* Practice Email*

Patient Details

Patient Name* Telephone* Email* Date of Birth*

Relevant Medical History*

Reasons for Scan*

Please specify (if applicable)

Areas of Interest*

Specific Tooth Numbers*

(Please enter numbers separated by commas)

Special Instructions*

Reporting Acknowledgement*

Upon receiving this referral, Maison Dental Specialists will act solely as an X-ray imaging centre, providing CBCT imaging strictly on a referral basis only.

Reporting on referred scans or radiographs is not provided. In accordance with IRMER 2017 Regulations, all radiographs and CBCT scans must be reviewed and formally reported in the clinical records by the referring practitioner or by a qualified radiologist.

By proceeding with this referral, the referring practitioner confirms that they will make their own arrangements for reporting of all radiographs and CBCT scans.

I acknowledge and confirm that I will make my own arrangements for reporting of all radiographs and CBCT scans.

CBCT Referral Form