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01277 205605
[email protected]

153 High Street, Brentwood, Essex, CM14 4SD

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Home
About
Referral Forms
Treatments
Finance Options
Contact

CBCT Referral Form

Sovereign House
First Floor
153 High Street
Brentwood
Essex CM14 4SD

T: 01277 205605
E: [email protected]
www.sovereignhousesdc.co.uk

"*" indicates required fields

Panoral / CBCT Scan Referral Form

Referrer's Name*

GDC No*

Practice Address*

Referrer Telephone

Referrer Mobile

Referrer Email*

Date*

Patient Details

Patient Title*

Patient Name*

Patient D0B*

Possibility of Pregnancy*

Yes

No

N/A

Patient Address

Patient Home Telephone

Patient Work Telephone

Patient Mobile

Patient Email*

Fees - The fee is payable by the patient at the time of the scan

Panoral (Please tick which image is required) - £55

OPG

DPT

Panoral Bitewings

CBCT (Please tick which image is required). Includes a report from the Radiologist - £230 to £260

Maxilla and Mandible

Maxilla Only

Mandible Only

Limited Volume

CBCT - Teeth/Area

CBCT (Please tick which image is required). No report - £130 to £160

Maxilla and Mandible

Maxilla Only

Mandible Only

Limited Volume

CBCT - Teeth/Area

Delivery is by Secure Portal. A password to retrieve your scan will be provided.

Justification for Radiograph*

Relevant Points

Attachments

Drop files here or

Accepted file types: jpg, jpeg, png, tiff, doc, docx, pdf, dicom, ppt, pptx, Max. file size: 30 MB, Max. files: 5.

Patient Consent*

I give my explicit consent for Sovereign House Specialist Dental Centre to process my personal data in accordance with the Privacy Notice.

Thank you for your referrals.

Name

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

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Sovereign House
First Floor
153 High Street
Brentwood
Essex CM14 4SD

Email: [email protected]
Phone: 01277 205605
Reception opening hours:
Mon, Tues, Thur, Fri 8.30 to 5.30 Wed 8.30 to 6.30

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