CBCT/OPT Referral Form

Referring Dentist Details

Dentist’s Name *

Dentist’s GDC Number *

Practice Address (including Postcode) *

Dentist’s E-mail *

Dentist’s Contact Telephone Number

Date of Referral *

Patient Details

Patient’s Title *
—MrMrsMsMissOther

Patient’s First Name *

Patient’s Last Name

Patient’s Date of Birth

Patient’s Address (including Postcode)

Patient’s Telephone Home

Patient’s Telephone Work

Patient’s Telephone Mobile

Patient’s Email *

CT Scans are NOT recommended for pregnant women because of danger to the foetus. Choose below as appropriate:
Patient is pregnantPatient is not pregnantPatient is unsure whether they are pregnant

Referral Details

CBCT/OPT Referrals:
CBCTDigital PanoramicMaxillaMandibleSinus

Radiographical Report (will be sent to Radiologist) *
YesNo

Patient to wear Radiographic Marker? *
YesNo

Implant Referrals:
Assessment AdviceProblems and DiagnosisSurgical Placement OnlySurgical Placement and RestorationAugmentation and Surgical Placement

Other Referral Options:
PaedsEndodonticSurgicalProsthoOrthodonticSpecialist Periodontal

Reason for referral:

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