Patient informationTitle * Mr.MissMrsMsDr.Other Practice * Please select....GlasgowCambuslang First name *Last name * Address * Contact details DOB * Type of referral *CT ScanOPTPlease tick all boxes that applyReason for referral and justification for CT scan CT scan area of interestMaxillaMandibleBothSmall SectionReason for referral and justification for digital OPT OPT area of interestLeft SideRight SideFull Mouth X-rays/Any other relevant files enclosed? *YesNo Please attach all relevant files:Upload Images:Upload Images:Upload Images:Upload Images:Upload Images:Upload Images:* File uploads are limited to 30mb Has the patient been referred before? *YesNo Any relevant medical history? *YesNo Please list all relevant history: Please indicate your preference for radiological interpretation of the dento-alveolar region:Please supply a Consultant Radiologist report (£90)I undertake to report on the scan myself as required by IR(ME)R 2000/2006Referring Practitioner Details *By clicking ‘send’ you are consenting to us replying, and storing your details. (see our privacy policy).
