01372 897197 / info@dentalelements.co.uk

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
Email
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)





Upload images

Referring Practitioner's Address/Stamp
Name
Address
Email
Signature
Date