Dentist Details
Name *
Name
Practice Address *
Practice Address
Patient Details
Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Medical History
Please list any relevant drugs
Smoking History
Required Scan
Scan for *
Reporting *
If Referring clinician will undertake reporting please select self report. If you would like a Consultant Radiologist Report on the OPT/CBCT please select below:
Payment for scan *
Approval
Clinician approval *
I, the referring dentist hereby agree to refer my patient detailed above for CBCT Scan / OPT Referral with Blyton Dental & that I have their consent to do so.