CBCT Referral

Digital Radiography Referral Form

* Indicates required field

Referring Dentists Name *

Practice Name *

Telephone *

Email *

Type of Scan *

Reason for Scan- PLEASE SPECIFY TEETH/AREAS TO BE SCANNED *

Is there a stent to be fitted? *

Patient Name *

Patient DOB *

Patient Address *

Line 1

Line 2

City

State

Zip Code

Country

Patient Telephone *

Patient Email *

Format Required *

How would you like to receive the scan? *

Reporting *

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 £240 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

Bath Spa Dentistry
19a James Street West, Bath, BA1 2BT
Tel: 01225 464346

Opening Hours:
Monday: 09:00 - 17:00
Tuesday: 09:00 - 18:00
Wednesday: 08:00 - 17:00
Thursday: 09:00 - 17:00
Friday: 08:30 - 14:00

Regulated by Care Quality Commission, General Dental Council and Financial Conduct Authority
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Bath Spa Dentistry Ltd is a registered company in England and Wales, registration number 06919668

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