Referrers details

Referrers name*

GDC Number*

Practice address*

Telephone Number*

Mobile Number*

Email Address*

Date of Referral*

Have you referred to us before?*
YesNo

Patient details

Patient name*

Patient email*

Date of birth*

Patient address*

Possibility of Pregnancy?*
YesNoN/A

Patient Home Telephone*

Patient Work Telephone*

Patient Mobile Number*

The fee is payable by the patient at the time of the scan.

Panoral - £61
(Please tick which image is required)*
OPGPanoral Bitewings

CBCT - £170
(Please tick which image is required)*
one jawboth jaws

Delivery Options:
Secure PortalCD

Justification for radiograph
Radiographs should provide information to confirm a diagnosis, or provide information that may affect the choice of treatment:

Relevant points from history, examination, radiographs
(please enclose copies of any radiographs of the area under investigation):

Please attach any relevant x-rays, OPG or images

Upload relevant radiographs or images

I confirm that the patient has consented to the sharing of their information for referral purposes.