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Home
About Us
Treatments
Implants
Invisalign
Team
Fees
Referral
Contact us

01932 248 348

Private Patients Registration

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5 The Green, Hersham Surrey, KT12 4HW

I’m interested in

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I’m interested in

CBCT & OPG Referral Form

Referring For?

Select the examination

OPG CBCT Endodontics Surgery / Sedation

Referring Dentist’s Details

Dentist’s name

GDC no

Practice Address

Telephone

Email

Patient Details

Patient’s name

Patient’s date of birth

Address

Patient`s Contact number

Appointment date (if booked

Gender

Male Female

Possibility of pregnancy?

Yes No

Area of interest

Both jaws with sinus (10 x 8.5cm) Both jaws (10 x 7cm) Quadrant (5 x 5cm) TMJ OPG

Teeth to be scanned

Patient to bring radiographic template?

Yes No

Template type?

Denture marked Separate template

Clinical indications

Reason for CBCT?

Implants Endodontics Sinus exam Oral pathology Bone graft Orthodontics Impacted teeth TMJ

CBCT format?

DICOM Files E2 3D-iVatech software

CBCT output

CD-ROM Email

2-D Digital Panoramic (OPG) required?

Yes No

Radiology report (+£85)

Yes No

Dose reduction required?

Yes No

Acceptance

I would like this patient’s radiographic examination to be reported upon I will make my own reporting arrangements

Payment Method

Patient to pay Invoice referring practice

Hersham Dental Practice
01932 248 348

5 The Green, Hersham Surrey, KT12 4HW

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Home
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Treatments
Implants
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Team
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Referral
Contact us

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