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:





IMAGE TYPE:
Indicate Imaging Service required - please tick
CBCTDPTIO-RADDIOSDSLR

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

CLINICAL JUSTIFICATIONS:
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

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