CBCT Referral Form

Patient's Name *

First

Last

Patient's Email

Patient's Telephone *

Patient's Address

Town

Patient's Postcode

Date of Birth *

Gender *

Male
Female

Scan required *

CBCT Scan - £120.00
OPG - £60.00

FOV *

Small FOV
Full Maxilla
Full Mandible
Both Jaws
High Resolution Small FOV (Endodontics)

Clinical Justification *

Implant Sites *

If not required for implants please write N/A

Radiographic Stent *

Yes
No
N/A

Will the patient be wearing a radiographic stent.

Clinical Evaluation - Report *

With Report + £60.00 any FOV
Without Report

If report is not required - I declare that I have the necessary qualification in order to evaluate the data requested. Alternatively, I will arrange for a Consultant Radiologist to evaluate the data.

Dentist's Name *

First

Last

GDC Number *

Dentist's Email *

Dentist's Telephone *

Practice Name

Practice Address

Town

Postcode

Declaration *

I declare that I have the necessary training in accordance with the current UK guidelines

Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment. 2nd Edition. FGDP(UK) & PHE 2020

Belgrave House Dental Practice

General Dentistry
Laser Dentistry
Periodontics
Implants
Orthodontics
Facial Aesthetics
Fees
Contact
Referral

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