CBCT Referral Form

Dentist details:
Date

DayMonthYear
Date
Patient details:
Title
Purpose of referral:
CBCT without report (£150 per zone)
CBCT with report (£300)
Declaration:
Type a question*

I have made the patient aware of referral
Type a question

I have Level 1 CBCT training to request this referral
Type a question*

I have Level 2 CBCT training to report on the scan
Type a question

I have Level 2 CBCT training to report on the scan
Should be Empty: