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Dental CBCT Scan REFERRAL

CBCT Scan Request

Colleague dentists, Please fill this form to request CBCT scan for your patients.

Comments

This field is for validation purposes and should be left unchanged.

Patient Details:(Required)

First Name: Last Name:

Date of Birth:(Required)

Patient's Address(Required)

Street Address Address Line 2 City Postcode

Email(Required)

Dentist's Details:(Required)

Prefix First Last

Role:(Required)

GDC Number:(Required)

Practice Full Address(Required)

Practice Name: Address City Postcode

Practice Contact Number:(Required)

Brief Patient History:(Required)

Reason For Scan:(Required)

CBCT Scan Requirements: All Scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque marker to be worn?(Required)

Yes

Field of View:(Required)

Full upper

Full Lower

Full Upper and Lower

Full Upper and Lower, inc TMJ

Option:

CBCT Scan Charges CD only £100

Additional Document Upload:

Max. file size: 512 MB.

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