Patient's Details:

Patient Reference (required)

Title (required)

Name (required)

Address (required)

Date of birth (required)

Phone

Mobile

Email (required)

Referring Dentist Details:

Referring Practitioner (required)

GDC Number (required)

Practice Name (required)

Practice Address (required)

Practice Phone (required)

Email (required)

Justification For CBCT (required under IR(ME)R 2017):

Please Indicate the Field of View Required:

Both ArchesFull MandibleFull Maxilla

Small Field of View:
5x5cm8x5cm

Please stipulate the exact teeth/area you require

Accompanying files