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