Dental CT Scan Referral

Referring Practitioner

Practitioner Name

Address

Telephone

Mobile

Your Email

Patient Details

Patient Name

Address

Patient Contact Number

Patient Alternative Contact Number

Patient Email

Date of Birth

Examination Required: (Parallel to occlusal plane unless requested otherwise)
CT MaxillaCT MandibleCT of both jawsPlease tick if you would like CT Maxilla to show 20+mm maxillary sinus (e.g. prior to sinus lift)

Patient to wear stent provided by own dentist? YesNo

Additional Information / Justification for Scan:

PLEASE NOTE:
Patient’s will be requested to make payment at the Scan appointment.
Please indicate if you prefer the referring practitioner to be invoiced

I as the referring practice take full responsibility for the clinical justification of the CT Scan and I agree it is fully my responsibility to review the scan and diagnose the radiograph. I understand Tooth Doctor (UK) Ltd holds no responsibility for the justification and the diagnosis of the radiograph.