Dental Imaging Referral Form

Dental Imaging Referral Form
Referring Dentist's Name*

First NameLast Name
Referring Dentist's Telephone*
Please enter a valid phone number.
Referring Dentist's Email*
example@example.com
Referring Dentist's Dental Practice*
Referring Dentist's GDC*
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

DayMonthYear
Date
Gender*

MaleFemaleOther
Patient Telephone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2

City

Post Code
Earliest Date To Scan The Patient*

DayMonthYear
Date
Who Are We Taking Payment From For The Imaging?*

DentistPatient
Referral Information
Which Service Do You Require For Your Patient?*

CBCT ScanOPG Scan
Select The Area To Be Scanned*
OPG Scan*
Select Area Of Interest
Upper Right

87654321
Lower Right

87654321
Upper Left

87654321
Lower Left

87654321
Clinical Indication For Referral
Justification For Imaging*

ImplantsSinus ExamZygomatic ImplantsImpacted TeethAirway StudyEndodonticsSinus LiftBone GraftRamos Bone GraftOrthodonticsTMJOrthognathicPerioChin Bone GraftOral Pathology
Any Other Comments
Any special dental or medical factors, such as known allergies or unusual medical treatments, should be noted.
The Patient consents under the referral process to have an x-ray exposure and understands what it involves. I have provided the patient with adequate information relating to the benefits and risks associated with the radiation dose. I am suitably qualified to request CBCT/OPG imaging. For children under the age of 16 the parent or guardian agrees*

Accept
I have read and agree to abide by The Tooth Spa's Standard Terms and Conditions*

Accept
The Tooth Spa's Standard Terms and Conditions can be found here
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Dental Imaging Referral Form

Patient Information

Referral Information

Select Area Of Interest