REFERRAL FORM

REFERRAL FORM

REFERRER DETAILS AND DELIVERY ADDRESS

PATIENT DETAILS

Radiographic template with patient?

AREA OF INTEREST CBCT ONLY

R
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L

CBCT FORMAT

2D IMAGING

EXTRAS

iTERO - INTRA ORAL

PAYMENT

JUSTIFICATION FOR X-RAY

CBCT OUTPUT

2D OUTPUT

RADIOLOGY REPORT

CLINICAL INDICATIONS (mandatory)

SIGNATURE

DATE

Head Office: 75 Harley Street, London, W1G 8QL

London - Manchester - Kent - Birmingham - Watford

Registered company no. 12866761

info@dental-scan.co.uk +44 (0) 20 7590 2020

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.

SIGNATURE

DATE

Head Office: 75 Harley Street, London, W1G 8QL

London - Manchester - Kent - Birmingham - Watford

Registered company no. 12866761

info@dental-scan.co.uk +44 (0) 20 7590 2020

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.

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