CBCT Referral Form Please enable JavaScript in your browser to complete this form.Patient's Name *FirstLastPatient's EmailPatient's Telephone *Patient's AddressTownPatient's PostcodeDate of Birth *Gender *MaleFemaleScan required *CBCT Scan - £120.00OPG - £60.00FOV *Small FOVFull MaxillaFull MandibleBoth JawsHigh Resolution Small FOV (Endodontics)Clinical Justification *Implant Sites *If not required for implants please write N/ARadiographic Stent *YesNoN/AWill the patient be wearing a radiographic stent.Clinical Evaluation - Report *With Report + £60.00 any FOVWithout ReportIf 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 *FirstLastGDC Number *Dentist's Email *Dentist's Telephone *Practice NamePractice AddressTownPostcodeDeclaration *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 2020Submit