This template is designed so that the dentist or specialist requesting the study delivers to the imaging center all the information needed to perform the CBCT with the best possible diagnostic quality while applying ALARA. Print and complete it, or adapt it to your clinic’s stationery.
CBCT study request
Request date: ___ / ___ / _______ Urgency: ☐ Scheduled ☐ Priority ☐ Urgent
Requesting professional data
First and last name: __________________________________________________
Specialty: ☐ General dentist ☐ Oral and maxillofacial surgeon ☐ Implantologist
☐ Endodontist ☐ Orthodontist ☐ Periodontist ☐ Other: _______________
License #: ____________________ Clinic/Office: _______________________
Email: _______________________ Phone: ____________________
Patient data
Full name: __________________________________________________
ID document: _____________________ Date of birth: ___ / ___ / _______
Sex: ☐ M ☐ F Age: ___ years Pregnancy?: ☐ No ☐ Yes ☐ N/A
Patient phone: ____________________ Email: _______________________
Insurance / coverage: __________________________ #: ______________________
Clinical indication
Reason for the study (free text):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Check all that apply:
☐ Implant planning · FDI positions: __________________________
☐ Pre-orthodontic study (3D cephalometry / airways / asymmetry)
☐ Endodontics (additional canals, fractures, periapical lesion) · Tooth: ____
☐ Impacted third molar / wisdom tooth · Tooth: ____
☐ Cystic / tumoral pathology / bone lesion
☐ Facial trauma / fracture
☐ TMJ (temporomandibular joint) · ☐ Unilateral ☐ Bilateral
☐ Sinus lift / maxillary sinus evaluation
☐ Root resorption
☐ Post-operative follow-up · Type of prior surgery: __________________
☐ Other: ______________________________________________________________
Anatomical region requested
☐ Full upper jaw ☐ Full lower jaw
☐ Both jaws (large FOV) ☐ Bilateral TMJ
☐ Specific sector / region: ________________________________________
Suggested FOV (Field of View)
☐ Small (≤ 6 × 6 cm) — Endodontics, single implant, third molar
☐ Medium (8 × 8 cm to 10 × 10 cm) — Sector, quadrant, or both quadrants
☐ Large (≥ 12 × 12 cm) — Orthodontics, cephalometry, TMJ, both full jaws
☐ Imaging center decides based on indication
Relevant prior history
Prior patient studies (panoramic, previous CBCT, etc.):
___________________________________________________________________
Relevant medical history (allergies, pacemaker, pregnancy, claustrophobia):
___________________________________________________________________
Current medications that may affect exposure or the study:
___________________________________________________________________
Additional observations for the radiologist
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Is a radiology report needed?
☐ Yes, with written report by radiologist
☐ Images only (no report)
☐ Images only at this time; report to be requested later if needed
Preferred delivery method
☐ Shared link to patient email · Email: ___________________________
☐ Shared link to requesting professional’s email
☐ Physical DVD/USB · Picked up by: ☐ Patient ☐ Other: ______________________
_________________________________
Requesting professional’s signature · License #
_________________________________
Office stamp / letterhead
This form should be given to the patient or sent directly to the imaging center before the study.
How to use this form
For the requesting dentist / clinician
- Be specific about the region of interest. "Right upper posterior sector" is better than "maxilla". "Implant at FDI position 46" is better than "lower molar".
- Indicate the actual clinical reason: implant planning, post-operative follow-up, suspected root fracture, pre-orthodontic evaluation, non-specific pain, etc. This guides the radiologist as to which structures to review carefully.
- If you have a preference for FOV (field of view), state it. If not, describe the region and let the imaging center choose the appropriate FOV. Remember: smaller FOV = lower dose and better spatial resolution.
- Note any relevant prior radiology studies. This lets the radiologist compare and, if applicable, avoid unnecessary duplicate studies.
For the imaging center
- If the information is ambiguous, contact the requester before acquiring the study. Repeating a CBCT due to insufficient FOV delivers extra radiation to the patient.
- Document in the patient’s file the referral form received and the clinical justification. For health audits and regulatory compliance, this record is critical.
- If the stated clinical reason is vague ("pain", "follow-up") and does not clearly justify the CBCT dose, consider contacting the requester to confirm before proceeding.