Patient Referral
Scans and Imaging
Your Details
Referrer’s Name:
*
GDC Number:
*
Practice Address:
*
Telephone Number:
Mobile Number:
Email Address:
*
Date of Referral:
Patient Details
Patient Name & Title:
*
Patient Email:
Date of Birth:
*
Patient Address:
*
Possibility of Pregnancy
Yes
No
N/A
Home Tel:
Images Required
Work Tel:
Mobile:
Panoral
OPG
Panoral Bitewings
CBCT
One Jaw
Both Jaws
Please attach any relevant x-rays, OPG or images
Justification for Radiograph
Radiographs should provide information to confirm a diagnosis, or provide information that may affect the choice of treatment:
Relevant points from history, examination, radiographs
(please enclose copies of any radiographs of the area under investigation):
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