Dental CBCT / OPG Referral Form

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All Fields Required (unless stated as Optional)

    Referring Dentist's Details (IRMER referrer)

    Patient's Details

    Justification for X-rays

    Implant treatment PlanningEndodontic AssessmentOrthodontic AssessmentImpact wisdom teeth assessment
    Full Upper Jaw (8*5 cm)Full Lower Jaw (8*5 cm)Both Upper and Lower Jaw (9*8 cm)Small Field (5*5 cm)

    Type of Imaging

    CBCT (3D Imaging)OPG (2D Imaging)

    Payment

    Dentist / PracticePatient

    How would you like to receive your CBCT?

    Cloud (via WeTransfer)USB (£10 fee will apply)

    Patient has a radiographic stent to wear during scan?

    YesNo

    Is the Patient Pregnant?

    YesNo
    Yes

    Urgent Appointment

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