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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

"*" indicates required fields

Patient Details

Name*
DD slash MM slash YYYY
Address*
Practice Address*
I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security
I have obtained consent*

To be completed by referring practitioner

Maxilla, Mandible or Both Jaws*
FOV*
Upper Right
Upper Left
Lower Right
Lower Left
Is the patient coming with a radiographic stent?*
Is the patient possibly pregnant?*
CBCT Return*

Radiographic Justification*

Cost £99 Per Arch

Payment*
Payment*
Consent*