Diagnostic Imaging Referral Form

Email address required to ensure a copy of referral form is sent to you for your records. All fields will need to be completed in the contact area. Referred by:
Patient Details: Preferred method of contactPhoneMobileEmail Enclosures: RadiographsDPT Imaging request: DPT-ONL CBCT scan(Please indicate regions of interest): Maxilla: R Lateral Anterior Sextant-Inter Sinus L Lateral Mandible: R Lateral Anterior Sextant-Inter Sinus L Lateral If sectional scan volume not adequate I will provide a full arch scan. Justification when treatment planning for dental implants: Maxilla: Confirm shape of residual alveolus Confirm descent of nasal/maxillary sinus prior to implant placement Mandible: Confirm shape of residual alveolus
Confirm position of mandibular canal/mental foramen prior to implant placement Consultant maxillofacial radiologist report required (Additonal £75.00) Any additional information: File Attachment: Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF [mfile file-attachment limit:10485760 filetypes:jpeg|jpg|png|doc|docx|pdf max-file:10] Please check this box to confirm the information within this form is true to the best of your knowledge