CBCT-scans

• Referrer’s Name: *
• GDC Number: *
• Practice Address: *
• Telephone Number:
• Mobile Number:
• Email Address: *
• Date of Referral:

• Patient Name & Title: *
• Patient Email: *
• Date of Birth: *
• Patient Address: *
• Possibility of Pregnancy:
  • Yes
  • No
  • N/A
• Home Tel:
• Work Tel:
• Mobile:

• • Panoral (Please tick which image is required) – £61
  • OPG
  • Panoral Bitewings

• • CBCT (Please tick which image is required) – £ 170
  • one jaw
  • both jaws

• Delivery Options:
• Secure portal
• CD

• Justification for radiograph
  Radiographs should provide information to confirm a diagnosis, or provide information that may affect the choice of treatment:

• Relevant points from history, examination, radiographs (please enclose copies of any radiographs of the area under investigation):

Please attach any relevant x-rays, OPG or images

Upload x-rays, opg and pictures of the case in the following formats: jpeg, jpg, gif, png. up to 3 images permitted, max size 3MB per image.