Dentist details:
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
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
Submit
Should be Empty: