ࡱ> uwt3 bjbj Zbb Ol  8 TZ &*\(|r@9%;%;%;%;%;%;%$' &)_%iN"_%2%2229%29%2v2! "5" &  %"5"%0&-"*R*5"2   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 Alliance Medical, BMI, Capio, Nuffield 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 295  FORMCHECKBOX  420  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 425  FORMCHECKBOX  580  FORMCHECKBOX SimPlant Basic (for SimPlant Pro or Master users only) Send via secure FTP215  FORMCHECKBOX  340  FORMCHECKBOX High Quality Kodak Prints (hardcopy only) Full Kodak Prints (with axials)375  FORMCHECKBOX  495  FORMCHECKBOX Extras Extra Kodak Prints (with axials)ADD +90  FORMCHECKBOX ADD +150  FORMCHECKBOX  Extra Paper Prints (no axials)ADD +35  FORMCHECKBOX ADD +50  FORMCHECKBOX  SimPlant OneShot feeADD +200  FORMCHECKBOX ADD +200  FORMCHECKBOX  Send results on CDADD +25  FORMCHECKBOX ADD +25  FORMCHECKBOX Express Service (images in 5 working days or less***) Express Service (Must book with IDT in advance)ADD +75  FORMCHECKBOX ADD +75  FORMCHECKBOX ***Please allow 10 working days for standard service INVOICE TO BE SENT TO : PATIENT****  FORMCHECKBOX  PRACTICE  FORMCHECKBOX   FORMTEXT      ****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 STERLING 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 hln246TVjlnxzǓLJǓ{lǓ`ljnOJQJUjOJQJUmHnHujOJQJUjOJQJUjOJQJU5OJQJmHnHuj5OJQJUj5OJQJU 5OJQJOJQJ5>*CJOJQJ CJOJQJjUmHnHu5CJOJQJCJjCJUmHnHu%    ud]u ud]u ud]u 1 fud]u  pud]u  pud]uud]u & Fud]u & Fp4>?MNOYZhijopq     " 6 ߸񢛎whjOJQJUmHnHujOJQJU5CJOJQJCJjCJUmHnHu CJOJQJ5>*CJOJQJjFOJQJUj5OJQJUjZ5OJQJUj5OJQJU 5OJQJjOJQJUOJQJjOJQJU(6 8 : D F ^ ` t v x      F J L X Z n ־ֳyrh`5CJOJQJ5>*CJOJQJ CJOJQJjCJUmHnHu CJOJQJ jCJOJQJUmHnHuj:CJOJQJU CJOJQJjCJOJQJUjOJQJUj{OJQJUOJQJjOJQJUmHnHujOJQJUjOJQJU"  L 4 x   t $d$Ifa$ d$If ud]u ud]u >ud]u ud]uud]u n p r | ~  " $ 2 4 P R f h j t v   < r z ֢֖֏~qi~5CJOJQJ56>*CJOJQJ]5>*CJOJQJ CJOJQJ CJOJQJj,OJQJUjOJQJU"jWOJQJUmHnHuOJQJmHnHujOJQJUOJQJjOJQJUmHnHujOJQJUjOJQJU& 2y d$If|$$IflFBY#0j$    4 la 1234JKYZ[\^klz{|}/0>?@ACPQ_ߜߎ߀jn CJOJQJUjCJOJQJUjCJOJQJUj 5>*U\j5>*U\ 5>*\jCJOJQJUjCJOJQJU CJOJQJ56CJOJQJ]5CJOJQJ CJOJQJ123\}~ueU$ d$Ifa$$ d$Ifa$ $d$Ifa$ KF"$If^" d$Ifa$$Ifl#j$  0j$4 laYIII< d$If$ d$Ifa$$$Ifl4r &BY#  0j$4 laJA d$If$$Iflr BY# 0j$4 la$ Rd$Ifa$AbczueU$ d$Ifa$$ d$Ifa$ $d$Ifa$ KF"$If^" d$Ifa$$Ifl#j$  0j$4 la_`abhiwxyz{5DEFGlm{|ݼݮݼݕҼ݇Ҽݼݼݼyj2 CJOJQJUj CJOJQJUjF CJOJQJU56CJOJQJ]j CJOJQJU5CJOJQJjZ CJOJQJUjCJOJQJU CJOJQJ 5>*\j5>*U\j 5>*U\/ZJJJ= d$If$ d$Ifa$$$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$$$Ifl4FBY#0j$    4 laEm]$ d$Ifa$$$Ifl\ BY#  0j$4 laEFg~Do$ d$Ifa$$ d$Ifa$ d$Ifc$$Ifl4#j$   0j$4 la|}#&',-;<=>ABCGHVWXZ[jCJOJQJUj CJOJQJUj CJOJQJU@CJOJQJj CJOJQJU CJOJQJ 5OJQJj CJOJQJU CJOJQJ5CJOJQJjCJOJQJU6o_RB$ 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$$$Ifl\ BY#  0j$4 lah|h$ d$If^a$ -d$If^ d$Ifc$$Ifl4#j$  0j$4 la#>Y\s`L$ d$If^a$ -d$If^ d$If~$$IflFTY#0j$    4 laYZp<sbN,sbN$ d$If^a$ d$If^ d$If~$$IflFTY#0j$    4 la[pstyz{0`cdijx¸¸jXCJOJQJUjCJOJQJUjlCJOJQJU5@CJOJQJ5CJOJQJjCJOJQJUjCJOJQJU CJOJQJ CJOJQJ 5OJQJ5CJOJQJ4.pcSJ d$If$ Rd$Ifa$ d$If$ d$Ifa$~$$IflFTY#0j$    4 la./`{k$ d$If^a$ d$If^ d$Ifa$$Ifl#j$  0j$4 laxyz{~   &'()*4э߆xjj.CJOJQJUjCJOJQJU CJOJQJ5CJOJQJ5>*CJOJQJjCJUmHnHu5>*CJOJQJjCJUmHnHujDCJOJQJU5CJOJQJ 5OJQJ CJOJQJjCJOJQJUjCJOJQJU%sfV$ Rd$Ifa$ d$If d$If^~$$IflFTY#0j$    4 lapfwn`UOOr^r  r #r^r J "ud]uud]uud8]u~$$IflFTY#0j$    4 la45  nprfǼ5CJOJQJCJ 6CJCJ 6CJ]CJCJ*jUmHnHu CJOJQJ CJOJQJ jCJOJQJUmHnHujCJOJQJUjCJOJQJUf7 J "ud]u$a$  9r #r^r  9r #r^r'0 &P /R . 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