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Call Us: 0118 966 5656
Patient Title (Required) ---MrMrsMsOther
Patient Surname (Required)
Patient Forename(s) (Required)
Address
Postcode
Date of Birth
Telephone (Required)
Email (Required)
Possibility of Pregnancy NoYes
Examination Required (Required) CT MaxillaCT MandibleBothOPG All images will be taken parallel to the occlusal plane unless you specify a different orientation below:
The clinical content for requesting a dental CBCT:
Relevant results of history, examination and other imagining:
What information do you want the dental CBCT examination to provide:
Define the anatomical area that the scan(s) should cover:
Patient to wear stent provided by dentist: NoYes
It is an IR(ME)R requirement that the reported images must be clinically evaluated and the findings recorded in the patient's notes. It is also required that the referrer is qualified and trained for this purpose. PLease confirm here by entering FULL NAME and GDC number below (required):
Referring practice:
Full name (Required)
GDC Number:
Telephone number (Required)
Accept Privacy Policy: Yes
Alternatively you can download the offline version of the CT Scan Request form by clicking here
Click here if you would like to make a dental referral
Submit your name and email address to download our Dental Implant Brochure.
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