CBCT Referral

CBCT Referral

Click here to download/print a referral form

    With TMJWithout TMJ

    Small volume (please indicate, If no teeth are selected, the whole jaw will be scanned)
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    PATIENT DETAILS

    Title First Name Last Name Suffix

    Street Address *
    Address Line 2
    Postal / Zip Code *
    City
    Country
    Possibility of pregnancy *

    YesNo

    MEDICAL HISTORY


    Radiographs available *

    REFERRING DENTIST'S DETAILS

    First Name Last Name

    Street Address
    Address Line 2
    Postal / Zip Code
    City
    Country

    PURPOSE & PROPOSED COURSE OF TREATMENT

    Patient to payAccount to referrer

    IRMER 2000 Regulations: We do not routinely report on scans or radiographs. To comply with the IRMER 2000 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We can arrange for a report to be prepared by a Consultant Radiologist if this is requested by you.

    To book an appointment or to know more about our services, please call
    01582 712 470 or email us at practicemanager@waysidedental.co.uk

    Get in Touch

    Contact us with your questions or to request a ring back. We'd love to hear from you.

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