Please fill in the form details or click on the button below to download our CBCT Imaging referral form
Please complete the following details:
Possibility Of Pregnacy?YesNo
To comply with the IR(ME)R 2000 regulations, all radiographs and CBCT scans are required to be justified, reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We are unable to provide a report for your requested radiographs and CBCT images unless you request one. We strongly recommend that all CBCT and other radiographic examinations are reported upon to rule out the possibility of coincidental pathology, and can arrange to provide a report for your requested images for an additional fee of £85 per image.
Please indicate which of the following two options is preferable:
You would like us to arrange for this patient’s radiographic examination(s) to be reported upon (£89 per image) (This report will be sent to you separately)
You are adequately trained and competent to interpret and report your own CBCT images.
Does the patient have a radiographic template?YesNo
Area Of InterestMaxillaMandibleBoth jaws
ImplantsOrthodonticsPathologyEndodonticsOral SurgeryBone GraftTMJSinus Lift
What type of image do you require?
2D Digital Panoramic
3D CBCT Imaging5cm x 5cm (1-4 teeth)8cm x 8cm (Both Jaws)5cm x 10cm (Single Jaw)10cm x 10cm (Both Jaws)
I'd like to be informed of exclusive offers and other practice information Yes