CBCT Referral "*" indicates required fields REFERRING DENTIST DETAILSDentist Name* DrMissMrMrsMs Prefix First Last GDC No.*Preferred contact number*Practice Name* Email* PATIENT DETAILSName* MrMrsMissMsDr Select Prefix First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Email* Telephone Number*Date of birth* Day Month Year Possibility of pregnancy*Please selectYesNoPAYMENT OPTIONS* Account to referrer Patient to pay Region of Interest and Purpose of ExaminationPurpose of Examination*Region of Interest* Upper Jaw. Lower Jaw. Small Volume. Endodontic Scan. Upper JawPlease specify teeth 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Lower JawPlease specify teeth 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 Delivery*Select delivery option Send me a CD Email password protected copy IRMER 2000 Regulations* I would like this patient's radiographic examination to be be reported by your Consultant Radiologist I will make my own reporting arrangements Extra InformationAny other information you would like to give us? e.g. specific imaging parameters / protocols / concerns
