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Nine Elms, Battersea
South Quay, Canary Wharf
Churchill Place, Canary Wharf
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CBCT Referral Form
Patient Name
Patient Date of Birth
Patient Gender
Male
Female
Patient Telephone
Patient Email
Is the patient coming with a radiographic template
YES
No
2D Imaging
Digital Panoramic (OPG)
Include TMJs
3D CBCT Imaging
CBCT 3d DICOM Files Format
Send with Imaging Viewer
Full Radiology Report
Yes +£90
No
Is the patient possibly pregnant
YES
No
Select teeth that need to be scanned
Include TMJs
Both Jaws
Maxilla
Sectional/Quadrant
Mandible
Maxilla (Upper jaw)
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
Mandible (Lower jaw)
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Clinical Indications/Relevant History/Clinical Question
Justification for X-ray
Select
Impacted Teeth
Sinus Exam
Endodontics
TMJ Assessment
Implants
Dental Trauma
Post Treatment
Pathology
Orthodontics
Periodontal
Malocclusion
Dento-Alveolar Morphology
Payment
Invoice to Doctor
Invoice to patient
Name of the Practitioner
Practice Name
Address
Practitioner Phone Number
Practitioner Email
The patient consents under the referral process to have an x-ray exposure and understands what it involves. I have provided the patient with adequate information relating to the benefits and risks associated with the radiation dose. For children under the age of 16 the parent or guardian agrees. I have read and agree to abide by Mouth Dental Ltd Standard
Terms and Conditions
.
This patient is subject to safeguarding
Send Now
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CBCT Referral Form
Home
Why Choose Us
About Us
New Patients
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GALLERY
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Training Room Hire
Courses
Corporate
Referrals
Contact Us
Email Us
How to Find Us
Give Feedback
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