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OPG/CBCT Referral Form
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OPG/CBCT Referral Form

"*" indicates required fields

Step 1 - Patient Details

Patient Name*

Title First Surname

Patient Address

Street Address Address Line 2 City Post Code

Patient Email*

Patient Phone Number*

Patient Date of Birth*

DD slash MM slash YYYY

Is there any possibility the patient is pregnant?*

Yes

Step2 - Referring Dentist's Details

Name of Dentist*

Practice Name*

Address*

Street Address Address Line 2 City Post Code

Dentist's Phone Number*

Dentist's GDC Number*

Dentist's Email*

Step 3 - Referral Details

Reason for referral and justification for CBCT Scan*

Relevant Dental History

All CBCT scans will be supplied on secure USB Flashdrives.

The referring dentist will be responsible for any reporting.

Scan Options*

Maxilla

Mandible

Both Arches

Price Options*

OPG £50

CBCT Scan Single Arch £125

CBCT Scan Upper & Lower Arch £200

Payment to be made by the patient on the day of the scan.

Please confirm if radiographic stent is required*

Yes

File Attachment

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.

Any Other Comments

For information about how we will use your personal details please see our Privacy Notice

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