CBCT Referral Form

CBCT Referral

Please fill out the form below.

Referring Dentist Details
Referring Dentists Name*
Practice Name*
Telephone*
Email*
Patient Details
Patient Name*
Patient DOB*
DD slash MM slash YYYY
Patient Telephone*
Patient Email*
Patient Address*
Scan Details
Type of Scan*
Reason for Scan*
PLEASE SPECIFY TEETH/AREAS TO BE SCANNED
Is there a stent to be fitted?*
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 £190
- 5.5 x 5 Scan with Report £300
- 8 x 8 Scan with Report £300
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?*
Marketing Consent
I agree to receiving marketing and promotional materials