CBCT & OPG referrals

Please use this from when referring OPG and CCT patients to the Practice.

We aim to send all scans via the selected delivery method within 48 hours of the scan being taken.

If there is a more urgent need please let us know in the comment section below and we will do our best to get it to you more quickly.

CBCT/OPG Referral form

Information about the referring clinician

Referring dentist name *

First

Last

Practice name *

Practice Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Practice Phone

Practice email address *

Information about the patient

Patient Name *

First

Last

Patient address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Date of Birth *

Patient Phone Number *

Patient email address *

Information about the referral

What image do you need?

Please take a CBCT Scan (FOV 100 mm x 85 mm)
Please take an OPG x-ray

Justification *

Non reporting disclaimer *

Please note that we are not able to provide a reporting service at this stage.

Payment information

Who is to pay for the image? *

Please invoice the patient at the time the image is taken.
Please invoice the referring dentist for the image

How do you want us to send the image?

How shall we send this to you? *

Please send the image via Drop box*
Please send the image via memory stick in the post
Please send the image via email (OPG only)

* Please include the email address that pertains to the relevant drop box account in the comments box at the end of this form.

Any other comment or information

Any other comment or information