Radiographic Image Referral Form

Dentist Name:

Dentist GDC No:

Email:

Telephone:

Address:

Patient Name:

DOB:

Email:

Telephone:

Address:

Type of Referral (tick box):

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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