CT Scan Referrals

Dental CT Scan Request Form

Patient's Details

Patient Name

Address

Date of Birth

Mobile Number

CT Scan Requirements

All scans will be parallel to the occlusal plane unless otherwise specified Radio-opaque marker to be worn?

Yes No

Clinical Justification for X-rays:

Maxila Mandible

Reason for scan and justification:

Dentist Referral

Referring Dentist's Name

Practice Address

Referrers Email address

Referrers Phone Number

GDC/GMC Number

Upload X Rays / Reports / Images

Consent

I consent to my personal data being collected and stored for the purpose of marketing communications.