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.

    REFERRING CLINICIAN:






    PATIENT DETAILS:





    Please select from the list the imaging service required:

    ADDITIONAL CLINICAL INFORMATION – CBCT, DPT & IO-RAD:
    Indicate regions of interest - please tick

    Maxilla:Right LateralAnterior sextant - inter sinusLeft Lateral
    Mandible:Right LateralAnterior sextant - inter foramenLeft Lateral

    CLINICAL JUSTIFICATIONS:
    Please indicate justification

    Maxilla:Confirm shape of residual alveolusConfirm descent of nasal/maxillary sinus
    Mandible:Confirm shape of residual alveolusConfirm position of mandibular canal/mental foramen

    Please define primary area of interest

    Consultant maxillofacial radiologist report required? (Additional fee of £85)

    File Attachment:
    Please include any relevant file attachment. We accept the following files: JPG, PNG, DOC, DOCX, PDF

    I have consent for providing the lead dental treatment

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