CBCT Referral form

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CBCT Referral form

Please complete this form to refer a patient to us for an OPG or CBCT scan.

This form can be completed by BOTH a referring dentist or an individual wishing to self refer themselves to the Practice for these images.

Any questions please email info@adelaidesquaredentist.co.uk or call us on 01234 342223

Email *

Referring dentist name *

Practice name *

Practice address *

Practice phone number *

Practice email address *

Patient name *

Patient address *

Patient date of birth *

YYYY

Patient phone number

Patient email address *

What image do you need? *

Please take an OPG

Please take a CBCT scan (FOV 100 mm x 85 mm)

Justification *

Please note that we are not able to provide a reporting service at this stage *

Agree

Disagree

Required

Who is paying for the image? *

The referering dentist

The patient

How shall we send this image to you? *

Web based file transfer (i.e. drop box)

Memory sick in the post

To be collected

Please give to the patient

Any comment or further information? *

Send me a copy of my responses.

Submit

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