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All fields will need to be completed in the contact area.
Indicate Imaging Service required - please tick
ADDITIONAL CLINICAL INFORMATION – CBCT, DPT & IO-RAD:
Indicate regions of interest - please tick
MAXILLARight LateralAnterior sextant - inter sinusLeft Lateral
MANDIBLERight LateralAnterior sextant - inter sinusLeft Lateral
If images are to support treatment planning of dental implants please indicate justification
MAXILLAConfirm shape of residual alveolusConfirm descent of nasal/maxillary minus prior to implant placement
MANDIBLEConfirm shape of residual alveolusConfirm descent of nasal/maxillary minus prior to implant placement
If images are to support Endodontic or surgical procedures please define primary area of interest
Consultant maxillofacial radiologist report required? (Additional fee of £85) YESNO
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Please check this box to confirm the information within this form is true to the best of your knowledge