REFERRAL FORM

DENTIST DETAILS & DELIVERY ADDRESS

PATIENT DETAILS


HOW WOULD YOU LIKE TO RECEIVE YOUR CBCT?
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3D IMAGING
CBCT (Please update area of interest in section below)


2D IMAGING
Digital Panoramic (OPG)


2D OUTPUT
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PAYMENT
Dentist/PracticePatientOn Account (Pre-arranged)


AREA OF INTEREST CBCT ONLY
MandibleMaxillaBoth Jaws

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

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Is the patient coming with a radiographic template?
YesNo


Is the patient possibly pregnant?
YesNo

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 FilesRomexis Viewer

JUSTIFICATION FOR X-RAY
Bone GraftImplantsEndodonticsImpacted TeethSinus ExamTMJOral PathologyOrthodonticsOther


EXTRAS
Extra Copy (An additional fee will apply)Radiology Report

CLINICAL INDICATIONS: (mandatory)

Full radiolologist report by Dr Jimmy Makdissi £85 (please allow 5-7 working days) YesNo