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REFERRAL FORM

REFERRAL FORM

REFERRER DETAILS AND DELIVERY ADDRESS

Name of Referrer:

Practice name:

Address:

Telephone:

Email:

PATIENT DETAILS

Appointment Date:

Time:

Appointment Date:

Time:

Name & Surname:

Date of Birth:

Telephone:

Date of Birth:

Telephone:

Email:

map

2D IMAGING

Panoramic (OPG/OPT)

Lateral Ceph CEPH

PA Ceph CEPH

Bitewings

PAYMENT

Practice

Patient

2D OUTPUT

Secure Link (JPG)

DICOM Files

Cloud Viewer (PACS)

Photopaper

CLINICAL INDICATIONS (mandatory)

SIGNATURE

DATE

Dental Scan Ltd.info@dental-scan.co.uk +44 (0) 20 7590 2020
Suite 17, 75 Harley Street, London, W1G 8QL

Our radiographers will always base the scanning protocol (field of view, resolution and expoosure settings) on the justification for referral, age and anatomy of the patient.

Dental Scan © 2021 | Contact | Careers | News | Privacy policy | Cookie policy | Tel: +44 (0) 20 7590 2020 | Reg no. 12866761

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