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This form is strictly for referring Dentist practitioners only!

You can refer your patient by completing the referral form below. Alternatively, you can download a copy of the referral form and send it to the practice via post or email.

CT SCAN £99.00

OPG £50.00

Download referral formDownload CT Scan Referral Form

Patient's Details
Referring Dentist Details
Medical History

(please include known allergies and current medication)

Referral Information




Comments (e.g. area to be scanned, Radiographic Guide etc)

Extra

CBCT scans will come with one CD and viewing software.






Security Code

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Data Protection Act

The information you provide will be held and processed in accordance with the Data Protection Act 1998. At no time will your personal information be passed on to other organisations for marketing or sales purposes.

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