CBCT Referrals

Date of Referral

Dentist Email (for report): *

Practice Name: *

Contact Number:

Dentist Name *

Patient Details

Practice Address:0 / 180

Patient Name:

Parent/Guardian name if Under 18:

Mobile:

Email:

Post Code:

Address:

D.O.B:

Other:

CHI Number:

Occupation:

RadioYesNoRelevant Medical History?

If yes, please advise:

Field of View:100x85100x7050x50

Vertical Position:MaxillaMandibleOcclusal

Tooth Position:RightIncisorLeftRight MolarLeft Molar

Image Option:Low DoseUltra-Low Dose

Voxel Size:Standard (0.200)Application (0.300)

Bone Density:HardNormal

Justification for exposure:

OPT prescription detailsYesNo

StandardFrontLeftRight

Justification for exposure:

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