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152 High Rd, Byfleet, Surrey, KT14 7RG / 01932 341415 / surreyperio@gmail.com

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CBCT-scans

Panoral / CBCT Scan Referral Form

Referrer Details

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

Patient Details

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

Fees – The fee is payable by the patient at the time of the scan

- Panoral (Please tick which image is required) – £50
- OPG
- Panoral Bitewings

- CBCT (Please tick which image is required) – £ 150
- 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):

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152 High Rd, Byfleet,
Surrey, KT14 7RG
01932 341415
surreyperio@gmail.com

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Last Updated: Jan 2022

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