Referrals

CBCT Referral Form

Several dentists in the South West refer their patients to us for CBCT scans using our state of the art technology, which is instrumental in planning high quality, advanced dental procedures.

Please complete the online form below.

    *required fields

    Referrer Details

    Patient Details

    Appointment date (if booked)

    Gender*
    MaleFemale

    Possibility of pregnancy?*
    YesNo

    Area of Interest:
    Both Jaws (8 x 8cm)Maxilla (8 x 5cm)Mandible (8 x 5cm)Quadrant (5 x 5cm)

    Patient to bring radiographic template?
    YesNo

    Radiographic Template Type:
    Denture MarkedSeparate Template

    Justification for CBCT:
    ImplantsEndodonticsSinus ExamTMJOral PathologyBone GraftOrthodonticsImpacted Teeth

    CBCT Format:
    DICOM FilesRomexis Viewer

    CBCT Output*:
    CD-ROMEmail

    Digital impression required? (STL file - additional £10):
    YesNo

    2-D Digital Panoramic (OPG) required:
    YesNo

    2-D Output:
    YesNo

    Dose Reduction Required?
    YesNo