Scan referrals

Dentists, if you would like to refer your patient to us for an OPG or CBCT scan, please complete and submit the online form below.

If you are referring your patient for Periodontic, Endodontic or Implants assessment or treatment, please click here.

Please supply as much information as possible. If you have any questions or difficulty using this form, please call or email us.

Patient details:

* required fields

Patient title Full name of patient*
Date of birth
Telephone* (landline and/or mobile)
Email address*
Address

Referring dentist details:

Full name of referring dentist*
Practice*
Position
Email Address*
Telephone*
Practice Address

Reasons for referral:

What type of scan do you require?

Justification for scan

General Dentistry
Impacted Teeth
Periodontal Assessment
Orthodontics

Implants
Sinus Graft
Oral Pathology

Indicate area of interest

Maxilla
Mandible
Both jaws
For all cases please indicate your specific area of interest: *

Radiographs and documents:

If you would like to include radiographs, photographs or text files with your referral, you may use the file upload facility below. Image upload
Image upload
Image upload
Image upload
Text file
Text file

Send form

Please type the code into the box below then click 'Submit'.

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