CT imaging referral

Referring Dentist

Name: *

Surgery Address: *

Postcode: *

Tel: *

Email: *

Patient Details

Name: *

Address: *

Postcode: *

Tel: *

D.O.B.: *

Person responsible for payment:

Patient

Referring Dentist

Patient to wear Stent (Radiographic Guide) provided by Referring Dentist:

Yes

No

Patient to wear Stent (Radiographic Guide) provided by St Ann's Imaging (from Â£125):

Yes

No

Examination Required:

Reason for Referral and Justification for Scan: *

Special Instructions (e.g. radiographic guides):

Format required by Dentist

Will you require:

What type of software are you using?: *

SimPlant

Nobel Guide

CT Scan Data: *

CD Posted to Dentist

CD Issued to Patient

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