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


    [multifile* multifile-596 id:upload_image]



    Referring Practitioner's Address/Stamp


    Name


    Address


    Email


    Signature


    Date