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Digital Radiography Referral Form
*
Indicates required field
Referring Dentists Name
*
Practice Name
*
Telephone
*
Email
*
Type of Scan
*
Cone Beam CT - mandible 8x8
Cone Beam CT - maxilla 8x8
Cone Beam CT - sextant 5.5x5
OPT
Reason for Scan- PLEASE SPECIFY TEETH/AREAS TO BE SCANNED
*
Is there a stent to be fitted?
*
Yes
No
Patient Name
*
Patient DOB
*
Patient Address
*
Line 1
Line 2
City
State
Zip Code
Country
Patient Telephone
*
Patient Email
*
Format Required
*
with viewing software
third party software compatible
How would you like to receive the scan?
*
on a disc
electronically
Reporting
*
Please provide the scan with a report
I will provide my own report
I have advised my patient of the following fees (payable at the time of the scan):
*
Scan without report £160
5.5 x 5 Scan with Report £220
8 x 8 Scan with Report £240
Please Note
To comply with IMER 2000 & IRR 2018 regulations all radiographs and scans must be reviewed and reported into the clinical records by the referring practitioner or by an appropriately trained individual.
We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.
If the referring practitioner prefers that they make their own arrangements for the reporting, please let us know in advance.
How did you hear about us?
*
I agree to receiving marketing and promotional materials
Submit
Home
About
Meet our Team
Fee Guide
0% Finance
Treatments
Dental Implants
General Dentistry
Cosmetic Dentistry
Hygiene Care
Facial Aesthetics
Contact
Blog
Dentists Area
Referrals
Courses
News