Submit this form to order a radiology report
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Day
-
Month
Year
DOB
Referring Clinician
*
Dr's First Name
Dr's Last Name
Referring Practice
Name of Dental Practice
Referrer's Email
*
We will forward your results and invoices to this email
Clinical Indications for Report / Clinical Question to Radiologist
*
Please provide relevant clinical history and specify areas of interest for the radiologist.
Date of Patient's Scan
-
Day
-
Month
Year
This helps to better understand the patient's history
Back
Next
Save
Save
Submit
Please, upload your DICOM files here (1GB max)
*
Browse Files
Drag and drop files here
Choose a file
Make sure the DICOM files you upload belong to the correct patient and the scan is NOT anonimysed.
Cancel
of
PAYMENT
*
Pay now via credit card
Invoice
*
prev
next
( X )
Standard Report (CBCT)
Turnaround - 5 working days
£
130.00
Express Report
Turnaround - 24 hours
£
180.00
OPG Report
£
80.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Referrer's Email For Invoicing
*
We will forward your invoice to this email
Please, select
*
£130 = Standard Report - 5 working days turnaround
£180 = Express Report - 24 hours turnaround
£80 = OPG Report
Should be Empty: