REFERRAL FORM

DENTIST DETAILS & DELIVERY ADDRESS

PATIENT DETAILS


CBCT OUTPUT
 USB Dropbox


2D IMAGING
 Digital Panoramic (OPG)


2D OUTPUT
 DVD USB Dropbox


PAYMENT
 Dentist/Practice Patient On Account (Pre-arranged)


AREA OF INTEREST CBCT ONLY
 Mandible Maxilla Both Jaws

(If no teeth are selected the whole jaw will be scanned)

 UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1
 UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8

 LR8 LR7 LR6 LR5 LR4 LR3 LR2 LR1
 LL1 LL2 LL3 LL4 LL5 LL6 LL7 LL8



Is the patient coming with a radiographic template?
 Yes No


Is the patient possibly pregnant?
 Yes No

Documents

Small documents can be uploaded here. If you are intending to send us documents over 2MB in size please send them seperately via email by clicking this link.

Document 1:
Document 2:
Document 3:
Document 4:

CBCT FORMAT
 DICOM Files Romexis Viewer

JUSTIFICATION FOR X-RAY
 Bone Graft Implants Endodontics Impacted Teeth Sinus Exam TMJ Oral Pathology Orthodontics

EXTRAS
 Extra Copy Radiology Report

CLINICAL INDICATIONS: (mandatory)

Full radiolologist report by Dr Jimmy Makdissi £85 (please allow 5-7 working days)  Yes No