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CBCT Referral Form

Complete the online form below to submit a CBCT referral

If you require any assistance in completing the form, please call 01892 254 879

  • Patient Details

  • DD slash MM slash YYYY
  • I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security
  • To be completed by referring practitioner

  • Cost £99 Per Arch