Dental imaging 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

Imaging request

Examination required
Please provide sufficient clinical information to allow us to select and justify the appropriate examination

Clinical indication for examination

(please tick all that apply)

Specify other indication (if selected above):

Indicate area of interest

Maxilla
Mandible
Both jaws
TMJ
Specific tooth number(s) / region (specify below)

Please indicate your specific area of interest*
Additional information

Image resolution (CBCT only)

Standard Definition (SD)

Suitable for general diagnostic assessment and most routine CBCT examinations.

High Definition (HD)

Higher-resolution imaging for cases where greater detail is clinically required, such as fine anatomical structures, endodontic assessment or detailed implant planning. Please note HD scans involve a higher radiation dose than Standard Definition scans.

Unsure — please advise

Urgency

Routine
Urgent

If urgent, please explain:

Reporting Arrangements (CBCT only)

I will make my own reporting arrangements
I will require a radiology report

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 1

Image upload 2

Text file 1

Text file 2

Send form

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

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