General dentistry
Missing teeth
ROOT CANAL TREATMENT
WORN TEETH
Cosmetic dentistry
DENTAL SEDATION
Straight teeth
FACIAL AESTHETICS
Radiographic Image Referral Form
Dentist Name:
Dentist GDC No:
Email:
Telephone:
Address:
Patient Name:
DOB:
Type of Referral (tick box):
Panoramic (OPG)Dental CBCT
Reason for Referral? *:
Define the anatomical area that the scan should cover? *:
What information do you want the dental CBCT examination to provide? *:
*The CBCT image will be reported on by the referring dentist as per your service level agreement - we can arrange for an outside source to report on findings at an additional cost. Important information: it is essential that you complete all sections of this form in full. All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.
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