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 LateralAnterior Sextant-Inter SinusL Lateral
Mandible:
R LateralAnterior Sextant-Inter SinusL 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

Please check this box to confirm the information within this form is true to the best of your knowledge