CBCT-Scans – Art Dental & Beauty

REFERRER DETAILS

Referrer’s Name: *

GDC Number: *

Practice Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Number: *

Email *

Email

Confirm Email

PATIENT DETAILS

Patient Name & Title: *

Patient Email: *

Email

Confirm Email

Date of Birth: *

Patient Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Possibility of Pregnancy:

Yes
No
N/A

Patient Contact Number

FEES – THE FEE IS PAYABLE BY THE PATIENT AT THE TIME OF THE SCAN

Panoral (Please tick which image is required) – £50

OPG
Panoral Bitewings

CBCT (Please tick which image is required) – £ 150

One Jaw
Two Jaws

Delivery Options:

Secure Portal
CD

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):