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
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Submit
Please, upload your DICOM files here (1GB max)
*
Browse Files
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Make sure the files belong to the correct patient and the scan is NOT anonimysed.
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of
PAYMENT
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Invoice
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Standard Report (CBCT)
Turnaround - 5 working days
£130.00
£
130.00
Express Report
Turnaround - 24 hours
£180.00
£
180.00
OPG Report
£80.00
£
80.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
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Expiration Month
Expiration Year
2026
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2034
2035
2036
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2042
2043
2044
2045
Expiration Year
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
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