New Patients 0114 350 3180 | Existing Patients 0114 350 3180
Book Online
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: Imaging Service requiredCBCTDPTIO-RADDIOSDSLR
ADDITIONAL CLINICAL INFORMATION – CBCT, DPT & IO-RAD: Indicate regions of interest - please tick
MAXILLAMANDIBLE
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 EndodonticsSurgical
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
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