Submit this form to order a radiology report

Submit this form to order a radiology report
Patient's Name

First NameLast Name
Patient's Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDOB
Referring Clinician

Dr's First NameDr's Last Name
Referring Practice
Name of Dental Practice
Referrer's Email
We will forward your results 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

DayMonthYear
2 digit day, 2 digit month, 4 digit yearThis helps to better understand the patient's history

Please, upload your DICOM files here (1GB max)

Make sure the files belong to the correct patient and the scan is NOT anonimysed.
Cancelof
PAYMENT:
3Beam is no longer able to accept payment by invoice. All reporting must be paid for in advance via bank card.

Standard Report (CBCT)

Turnaround - 5 working days

£130

Express Report

Turnaround - 24 hours

£180

OPG Report

£80

Total