Patient Details
* Required
Email address
*
Your email
Title
*
Mr
Mrs
Miss
Ms
Dr
Other
Date of Birth
*
MM
/
DD
/
YYYY
Name
*
Your answer
Tel number (home)
Your answer
Address
Your answer
Post Code
*
Your answer
Tel number (mobile)
Your answer
Name
Your answer
Telephone number
*
Your answer
Address
Your answer
Email
Your answer
Postcode
*
Your answer
Medical History
Your answer
Reason for referral and justification for CBCT Scan/ OPG/Ceph
*
Your answer
Please select area(s) for CBCT Scan
*
Maxilla (full)
Mandible (full)
Maxilla (sectional)
Mandible (sectional)
Maxilla and Mandible (full)
Maxilla and Mandible (sectional)
Maxilla (including Zygoma bone)
TMJ joints.
OPG (full)
OPG (sectional)
Cephalometric radiograph
Image stent provided?
Yes
No
Clear selection
Format of OPG required
(CDs or Flash Drives incur additional cost)
OPG on photographic paper
OPG on CD
OPG as email attachment
Format of CBCT Scan required
CBCT Scan on CD
CBCT Scan on Google Drive (Dicom files)
CBCT Scan in Dropbox (Dicom files)
Do you have additional files to send in support of this referral?
Yes
No
Clear selection
Referring Practitioner's GDC number.
Your answer
Would you require a report?
*
Yes
No
Please provide reason why you do not require a report, such as qualifications or other evidence that you can report on the scan yourself.
Your answer
A copy of your responses will be emailed to the address you provided.
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