CBCT

DIGITAL PANORAMIC REFERRAL DETAILS

Digital Panoramic *

CBCT EXAMINATION REFERRAL DETAILS

Full Arch *

Imaging stent supplied by referring dentists *

Imaging stent required *

PATIENT DETAILS

Name *

Date of Birth *

Address

Street Address *

Address Line 2

Post Code *

City

Possibility of Pregnancy *

Phone (Mobile) *

Phone (Home)

Email *

MEDICAL HISTORY

Medical History

Radiographs Available *

REFERRING DENTIST'S DETAILS

Name *

Date

Address

Street Address *

Address Line 2

Post Code *

City

Phone No

Email *

PURPOSE & PROPOSED COURSE OF TREATMENT

Further Info *

Payment *

IRMER 2000 Regulations: We do not routinely report on scans or radiographs. To comply with the IRMER 2000 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We can arrange for a report to be prepared by a Consultant Radiologist if this is requested by you.

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DIGITAL PANORAMIC REFERRAL DETAILS

CBCT EXAMINATION REFERRAL DETAILS

PATIENT DETAILS

Address

MEDICAL HISTORY

REFERRING DENTIST'S DETAILS

Address

PURPOSE & PROPOSED COURSE OF TREATMENT

Phone Number

Our Location

Opening Hours