CBCT Referral Form

Before you submit

Please ensure you have the patient’s consent before submitting their details.

Please include the clinical reason for the CBCT scan and upload any relevant notes, radiographs or supporting documents within the form.

What happens next?

Our team will review the referral and contact the patient or referring practice to arrange the scan as needed.

If any further clinical information is required before the scan can be arranged, we will get in touch directly.

Secure referral form

Please fill in the details below as accurately as possible.

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Referring Dentist Details

Please provide the details of the referring dentist and practice.

Referring dentist name *

First

Last

Practice name *

Practice / dentist email address *

Practice telephone number *

GDC number

Practice address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Details

Please provide the patient's details so our team can process the referral.

Patient full name *

First

Last

Patient date of birth *

Patient email address

Patient telephone number *

Patient address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Treatment Information

For patients requiring CBCT imaging or diagnostic scan referral.

Reason for referral *

Clinical notes

Relevant medical history

Urgency *Please selectRoutineSoonUrgent

address Details Patient

Consent

Consent confirmation *

• I confirm the patient has consented to this referral and the sharing of their details with the practice.

Submit Secure Referral