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:

100x85100x7050x50

MaxillaMandibleOcclusal

RightIncisorLeftRight MolarLeft Molar

Low DoseUltra-Low Dose

Standard (0.200)Application (0.300)

HardNormal

Justification for exposure:

YesNo

StandardFrontLeftRight

Justification for exposure: