Panoral / CBCT Scan Referral Form

Referrer's Name

GDC Number

Practice Address

Tel

Mob

Date

Title

Patient Name

DOB

Address

Possibility of Pregnancy

Yes

N/A

Home Tel

Work Tel

Mobile

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

Please specify teeth / area

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

Maxilla and mandible

Maxilla Only

Mandible Only

Limited volume

Please specify teeth / area

Delivery Options:

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

Justification for radiograph

Radiographs should provide information to confirm a diagnosis, or provide information that may affect the choice of treatment.

Relevant points from history, examination, radiographs (please enclose copies of any radiographs of the area under investigation)

Attachments

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