Patient information Title * Mr. Miss Mrs Ms Dr. Other First name * Last name * Address * Contact details DOB * Type of referral * CT Scan OPT Please tick all boxes that apply Reason for referral and justification for CT scan CT scan area of interest Maxilla Mandible Both Small Section Reason for referral and justification for digital OPT OPT area of interest Left Side Right Side Full Mouth X-rays/Any other relevant files enclosed? * Yes No 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? * Yes No Any relevant medical history? * Yes No 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 2000/2006 Referring Practitioner Details *By clicking ‘send’ you are consenting to us replying, and storing your details. (see our privacy policy).
