Patient name

Patient address

Patient postcode

Patient date of birth

Patient telephone

Patient email

Patient medical history

Patient medication

Smoking status
SmokerNon Smoker

Referring Dentist Name

Referring Practice

Referring Practice Address

Referring Practice telephone

Treatment Requested

Select if required
SedationLocal Anaesthetic

Contact email

Attach Radiographs (if appropriate) 10mb limit. Jpg, Png or Pdf accepted

Patient name

Patient address

Patient postcode

Patient date of birth

Patient telephone

Patient email

Patient medical history

Required Scan: (select one only)
DIGITAL OPTCONE BEAM CT SCAN - MAXILLACONE BEAM CT SCAN - MANDIBLECONE BEAM CT SCAN - BOTH JAWSCONE BEAM CT SCAN - SEXTANT

Indicate tooth at centre of sextant (if applicable)

Clinical justification:

Payment
PatientInvoice Practice

Referring Dentist Name

Referring Practice

Referring Practice Address

Referring Practice telephone

REPORTING
REFERRING CLINICIAN WILL UNDERTAKE REPORTINGCONSULTANT RADIOLOGIST REPORT

Fees: OPT £80.    SEXTANT £120.    SINGLE JAW £150.    BOTH JAWS £200.

Contact email

Any additional info (optional)