Fusion Radiology Ltd
Dental CBCT Scan Booking Form
Email
aziz.ambia1@nhs.net
Phone 01582 249242 / 07828634357
Patient Full Name
*
Patient Address, include Post Code
*
Date of Birth
*
Patient contact number
Dentist Name
*
Dentist Email
*
Practice Address
Postcode
Dentist phone number
*
GDC Number
*
Area of interest
*
Preferred dated to be scanned
Reason for request / Notes
*
Stent YES/NO If patient needs to wear radio opaque marker during CT scan
Yes
No
Service request
CT scan only
OPG X-ray only
Radiology report only
CT & Radiology report
Signature
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