ࡱ> tvs3 bjbj VbbX Kl0 8* T~ 0&NJ:tn<W&Y&Y&Y&Y&Y&Y&' *Y&Q`"Y&Z&ZZZW&ZW&ZlZ"+#S#B p0 C#S#&0&K#+V+S#Z00 Complete the IDT Appointment Card and make a photocopy of the inside with the referring dentists signature. REFERRING DENTIST MUST SIGN THE IDT APPOINTMENT CARD. COMPLETE AND SIGN this form and fax it to IDT on +44 (0)20 8600 3549 or post it to: Image Diagnostic Technology Ltd, Unit GC, Westpoint, 36-37 Warple Way, London W3 0RG along with the copy of the signed Appointment Card. Give the original of the Appointment Card to your patient to take to the hospital appointment. HOSPITAL DETAILS*: AT WHICH IDT SCANNING SITE IS THE PATIENT TO BE SCANNED?  FORMTEXT _______________________ HAS APPOINTMENT BEEN MADE? YES  FORMCHECKBOX  DATE OF SCAN:  FORMTEXT       TIME OF SCAN:  FORMTEXT       NO  FORMCHECKBOX  HOSPITAL WILL CONTACT PATIENT TO ARRANGE REGION TO BE SCANNED: MAXILLA  FORMCHECKBOX  MANDIBLE  FORMCHECKBOX  BOTH  FORMCHECKBOX  *Do not use this form for Blackrock Clinic, Charlemont Clinic or other Private Hospitals that set their own prices  PATIENT DETAILS: NAME:  FORMTEXT       ADDRESS:  FORMTEXT       POST CODE:  FORMTEXT       TELEPHONE NO:  FORMTEXT       DATE OF BIRTH:  FORMTEXT        REFERRING DENTIST/SURGEON : NAME:  FORMTEXT       SIGNED: _____________________ ADDRESS**:  FORMTEXT       REG NO:  FORMTEXT       TELEPHONE NO:  FORMTEXT       EMAIL ADDRESS**:  FORMTEXT       **Results will be sent to this address REFORMATTING OPTIONS (includes cost of CT Scan): ONE JAWBOTH JAWSSimPlant Planner format (referrer must have a SimPlant software licence or add the OneShot fee) Send via secure FTP  FORMCHECKBOX OR via Email  FORMCHECKBOX 425  FORMCHECKBOX  605  FORMCHECKBOX SimPlant Advanced format (referrer must have a SimPlant software licence or add the OneShot fee) Send via secure FTP  FORMCHECKBOX OR via Email  FORMCHECKBOX 615  FORMCHECKBOX  835  FORMCHECKBOX SimPlant Basic (for SimPlant Pro or Master users only) Send via secure FTP310  FORMCHECKBOX  490  FORMCHECKBOX High Quality Kodak Prints (hardcopy only) Full Kodak Prints (with axials)540  FORMCHECKBOX  715  FORMCHECKBOX Extras Extra Kodak Prints (with axials)ADD +130  FORMCHECKBOX ADD +220  FORMCHECKBOX  Extra Paper Prints (no axials)ADD +50  FORMCHECKBOX ADD +75  FORMCHECKBOX  SimPlant OneShot feeADD +300  FORMCHECKBOX ADD +300  FORMCHECKBOX  Send results on CDADD +35  FORMCHECKBOX ADD +35  FORMCHECKBOX Express Service (images in 5 working days or less***) Express Service (Must book with IDT in advance)ADD +110  FORMCHECKBOX ADD +110  FORMCHECKBOX ***Please allow 10 working days for standard service INVOICE TO BE SENT TO : PATIENT****  FORMCHECKBOX  PRACTICE  FORMCHECKBOX  ****Images will be held until payment is received BOOKING FORM TO BE SENT TO IDT USE THIS FORM FOR PUBLIC HOSPITALS ONLY You must be a Registered IDT User to use this form Effective 2007-01-01 ALL PRICES IN EURO Cheques should be sent to IDT at Unit GC, Westpoint, 36-37 Warple Way, London W3 0RG Alternatively please phone us on +44 (0)20 8600 3540 with Credit Card details hln:<PRT^`~|pajOJQJUmHnHujOJQJUjOJQJUjOJQJU5OJQJmHnHuj5OJQJUj5OJQJU 5OJQJOJQJ56CJOJQJ]5>*CJOJQJ CJOJQJjUmHnHu5CJOJQJCJjCJUmHnHu"w  ud]u ud]u  fud]u  pud]u  pud]uud]u  ud]u & Fud]u & FH'12@ABMN\]^cdestuw ĹīĹĝ֑֊spf^W CJOJQJ5CJOJQJ5>*CJOJQJCJjCJUmHnHu5>*CJOJQJ CJOJQJjFOJQJUj5OJQJUjZ5OJQJUj5OJQJU 5OJQJjOJQJUOJQJjOJQJUmHnHujOJQJUjnOJQJU"    " 6 8 : D F ^ ` t v x     홒sl_jCJUmHnHu CJOJQJ jCJOJQJUmHnHuj:CJOJQJU CJOJQJjCJOJQJUjCJOJQJUj{CJOJQJUjCJOJQJU jCJOJQJUmHnHujCJOJQJU CJOJQJjCJOJQJU$   L 4 x   t $d$Ifa$ d$Ifud8]u ud]u ud]u ud]uud]u ud]u   F J L X Z n p r | ~  " $ 2 4 P R f h j t v    < ҷ۫ҷ۷ۃҷwҷp CJOJQJj,OJQJUjOJQJU"jWOJQJUmHnHuOJQJmHnHujOJQJUjOJQJUmHnHujOJQJUjOJQJUOJQJ CJOJQJ5CJOJQJ5>*CJOJQJ CJOJQJ+< r z 1234JKYZ[\^klz{|}-.<ȽȯȽȅȽwȽjCJOJQJUjCJOJQJUj 5>*U\j5>*U\ 5>*\jCJOJQJUjCJOJQJU CJOJQJ56CJOJQJ] CJOJQJ5>*CJOJQJ5CJOJQJ56>*CJOJQJ]- 2y d$If|$$IflFBY#0j$    4 la23\}~xl\$ d$Ifa$ $d$Ifa$ d$If KF"$If^" d$Ifa$$Ifl#j$  0j$4 laYIII< d$If$ d$Ifa$$$Ifl4r &BY#  0j$4 laJA d$If$$Iflr BY# 0j$4 la$ Rd$Ifa$?`awueU$ d$Ifa$$ d$Ifa$ $d$Ifa$ KF"$If^" d$Ifa$$Ifl#j$  0j$4 la<=>?ANO]^_`eftuvwx|}  />ߵ߭ߟ߭߆x߭߭j CJOJQJUjF CJOJQJU56CJOJQJ]j CJOJQJU5CJOJQJjZ CJOJQJUj 5>*U\j5>*U\ 5>*\ CJOJQJjCJOJQJUjn CJOJQJU/ZJJJ= d$If$ d$Ifa$$$Iflr &BY#  0j$4 laJA d$If$$Iflr BY# 0j$4 la$ Rd$Ifa$ p$ d$Ifa$$ d$Ifa$ d$Ifa$$Ifl#j$  0j$4 lao_RB$ d$Ifa$ d$If$ d$Ifa$$ d$Ifa$$$Ifl4FBY#0j$    4 la?m[$ "d$Ifa$$$Ifl\ BY#  0j$4 la>?@Aeftuvx|}"#1234789üüj CJOJQJUj CJOJQJU@CJOJQJj CJOJQJU CJOJQJ 5OJQJj CJOJQJUj2 CJOJQJUjCJOJQJU CJOJQJ5CJOJQJ6?@aw<o$ d$Ifa$$ d$Ifa$ d$Ifc$$Ifl4#j$   0j$4 lao_RB$ d$Ifa$ d$If$ d$Ifa$$ d$Ifa$$$Ifl4FBY#0j$    4 lam]M@0$ d$Ifa$ d$If$ d$Ifa$$ d$Ifa$$$Ifl\ BY#  0j$4 lam ]$ d$Ifa$$$Ifl\ BY#  0j$4 lad~j$ d$If^a$ d$If^ d$Ifc$$Ifl4#j$  0j$4 la4NTsbN$ d$If^a$ d$If^ d$If~$$IflFbY#0j$    4 la9<=KLMOPehimno}~ثثjXCJOJQJUjCJOJQJUjlCJOJQJU5@CJOJQJjCJOJQJU CJOJQJ 5OJQJ5CJOJQJ5CJOJQJjCJOJQJUjCJOJQJU CJOJQJ2NOe4sbN$sbN$ d$If^a$ d$If^ d$If~$$IflFbY#0j$    4 lapcSJ d$If$ Rd$Ifa$ d$If$ d$Ifa$~$$IflFbY#0j$    4 la!QTUZ[ijklopuvxjj.CJOJQJUjCJOJQJU5CJOJQJ5>*CJOJQJjCJUmHnHu5>*CJOJQJjCJUmHnHujDCJOJQJUjCJOJQJUjCJOJQJU CJOJQJ 5OJQJ CJOJQJ5CJOJQJ) Qlk$ d$If^a$ d$If^ d$Ifa$$Ifl#j$  0j$4 lawjZ$ Rd$Ifa$ d$If d$If~$$IflFTY#0j$    4 laHhwn`UOOr^r  r #r^r f"ud]uud]uud8]u~$$IflFTY#0j$    4 laGHIgh5CJOJQJCJ 6CJCJ 6CJ]CJCJ*jUmHnHu CJOJQJ CJOJQJjCJOJQJUC f"ud]u$a$  9r #r^r  9r #r^r#0 &P . 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