Image of dentist Dr Alfonso Rao sat in his dentistry chair, in his scrubs, smiling at the camera.

CT Scan Referral Form

Fill in the form below and a member of our team will be in touch.

CT Scan Referral Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Referring Practitioner

Practitioner Name*

Phone*

Email*

Practice Address*

Street Address Address Line 2 City Postcode

Dentist Signature*

Untitled

Patient Details

Patient Name*

Patient Phone*

Patient Email

Date of Birth*

Patient Address*

Street Address Address Line 2 City Postcode

CT Scan Requirements

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque markers to be worn? Yes/No*

SCAN ON CD

WE TRANSFER

I undertake to report on the scan as required by IR (ME)R 2000/2008

DROPBOX

Please supply a radiologist’s report

CT SCAN CHARGES:*

CBCT with Radiologist Report – £190.00

CBCT without Radiologist Report – £170.00

TOTAL*

DISCLAIMER: Under the Referral Scan Request Terms the dental CBCT images will be reported on by the REFERRING PRACTICE. The referring practice will then be responsible for ensuring that the clinical evaluation takes place, is properly recorded and the patient fully informed.

Refer to Define Dental Clinic?

We provide the highest quality clinical care alongside peerless results in general, cosmetic and restorative dentistry.
Contact us to refer your patient today.

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CT Scan Referral Form