New Patients 0114 350 3180 | Existing Patients 0114 350 3180
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.
Please select from the list the imaging service required:
Imaging Service requiredCBCTDPTIO-RADDIOSDSLR
ADDITIONAL CLINICAL INFORMATION – CBCT, DPT & IO-RAD:
Indicate regions of interest - please tick
Please indicate justification
Please define primary area of interest
Consultant maxillofacial radiologist report required? (Additional fee of £85)
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