OPG/CT Scan Referral Form

OPG/CT Scan Referral Form

Oral Pantomogram/ Cone-Beam Computerised Tomography Scan
Name of the Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Mobile Number:*
E-mail*
example@example.com
Address:*

Home Name/Number

Street Address

Town/CityCounty

Post Code
Type of Referral*

UrgentRoutine
Type of Xray/CBCT Required*

CBCT 8cmx8cmFull OPGPartial OPGExtraoral Bitewing
If CBCT, please list quadrant here:
Relevant Medical History*
Reason for Referral*
Planned Treatment:*
Please include tooth nos. and/or site.
Referring Clinic Name:*
Referrer’s Name:*

First NameLast Name
Referrer's GDC/GMC no.*
Referrer's Phone:*
Referrer's E-mail*
example@example.com
Referring Clinic Address:*

Street Address

Street Address Line 2

Town/CityCounty

Postal / Zip Code
Please verify that you are human*
CBCT: X-ray Tariff

Dentsply Sirona Orthophos S 3D CBCT/Xray Machine

(Please advise the patient of the fees before submitting a referral form)

Full OPG/ OPT - £55

Partial OPG / OPT - £55

Extraoral Bitewings - £55

CBCT - £250 sent through via Sicat Viewer (email) - No report included
Should be Empty: