Patient Details

    Please complete the following details:

  • Referring Dentist Details

    Please complete the following details:

  • 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.
  • You would like us to arrange for this patient’s radiographic examination(s) to be reported upon (£85 per image) (This report will be sent to you separately)

    You are adequately trained and competent to interpret and report your own CBCT images.

  • Imaging Details

    Please complete the following details:

  • 18
    17
    16
    15
    14
    13
    12
    11
  • 21
    22
    23
    24
    25
    26
    27
    28
  • 48
    47
    46
    45
    44
    43
    42
    41
  • 31
    32
    33
    34
    35
    36
    37
    38
  • Image Required

    What type of image do you require?

    Yes
  • One The Gallery needs the contact information you provide to us to contact you about a referral. You may unsubscribe from these communications at anytime. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, check out our Privacy Policy.

  • I'd like to be informed of exclusive offers and other practice information Yes
  • *By clicking 'Submit' you are consenting to us replying, and storing your details. (see our privacy policy).