Refer your patient

CBCT Referral Service

To book a scan appointment

Address: 2, Upper Fairfield Road, Leatherhead, Surrey, KT22 7HH.

Tel: 01372 897197

Email: info@dentalelements.co.uk

Complete your scan request

10 minute appointments are available. Please call the practice or complete the form below.

Patient's Details

Patient's Name

Date of Birth

Address

Postcode

Home phone

Mobile

It is an IR(ME)R requirement that the Referrer provides sufﬁcient clinical information for the x-ray procedure to be justiﬁed. Please provide a brief clinical history and state the questions that the OPG or CBCT examination is designed to answer.

Please denote the area to be scanned. All images will be taken parallel to the occlusal plane unless you specify a different orientation

Request (tick as appropriate)

CT MandibleCT MaxillaOPG11cm x 11cm large field implantFull arch scan

Upload images

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Referring Practitioner's Address/Stamp

Name

Address

Signature

Date