CBCT Referral Form

REFERRING DENTIST DETAILS

    Referring Dentist Details

    GDC Number*
    Title*
    Dentist First Name*
    Dentist Last Name*
    Dentist Phone*
    Dentist Email*

    REFERRING PRACTICE DETAILS

    Practice Name*
    Practice Address*
    Practice City*
    Practice Telephone*
    Practice Email*

    REFERRING PATIENT DETAILS

    Patient Name*
    Patient Address*
    Patient City*
    Patient Postal Code*
    Patient Date of Birth*
    Patient Telephone*
    Patient Email*
    Remarks / Comments*

    Important Information

    We can take an OPG scan and email this out to the patient or the referring dentist. With CBCT scanning we ask the patient to bring a ‘dongle’ with them so that we can download the image to it and they can take it back to the referring dentist.

    Select Sports FootballTennisPole-vault