CBCT Referrals Date of ReferralDentist Email (for report): *Practice Name: *Contact Number:Dentist Name *Patient DetailsPractice Address:0 / 180Patient Name:Parent/Guardian name if Under 18:Mobile:Email:Post Code:Address:D.O.B:Other:CHI Number:Occupation:Patient HistoryRadioYesNoRelevant Medical History?If yes, please advise:CBCT Prescription DetailsPlease Tick the relevant boxes and provide further details in the space given.Field of View:100x85100x7050x50Vertical Position:MaxillaMandibleOcclusalTooth Position:RightIncisorLeftRight MolarLeft MolarImage Option:Low DoseUltra-Low DoseVoxel Size:Standard (0.200)Application (0.300)Bone Density:HardNormalJustification for exposure:OPT prescription details OPT prescription detailsYesNoStandardFrontLeftRightJustification for exposure: Send Message
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