CBCT Scan Referral Form

Dentist Name *

Dentist GDC No

Dentist Email *

Dentist Telephone

Dentist Address *

Patient Details

Patient Name *

First

Last

Patient DOB (DDMMYYYY) *

Patient Email *

Patient Telephone

Patient Mobile

Patient Address

Referring Details

Reason for referral and clinical justification for CBCT scan? *

Define the anatomical area that the scan should cover: *

What information do you want the dental CBCT examination to provide? *

Patient to wear stent provided by dentist? *

Yes
No

Upper Teeth

Lower Teeth

Please Tell Us Your Preferences *

Patients to pay at visit:
Practice to pay fees:

The CBCT image will be reported on by the referring dentist as per your service level agreement - we can arrange for an outside source to report on findings at an additional cost. Important information: it is essential that you complete all sections of this form in full. All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

Signature of referring dentist

Digital Signature

Click or drag a file to this area to upload.

OR

Type Signature

If you do not have a digital version of your signature available please type name in box above and check the box below to acknowledge the inclusion of all data required for us to proceed

Acknowledgment *

Yes

Patient Details

Referring Details

Signature of referring dentist

OR

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practice Address

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E-mail

phone

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Thursday	9:00 AM - 5:00 PM
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Saturday	Closed
Sunday	Closed