CBCT Scan Referral Form

Welcome to the dentist referrals page. Your referral will be managed by our care coordinator who will contact your patients directly and arrange an assessment appointment at the most convenient time.

You will also receive an acknowledgment of your referral. At the initial assessment appointment, patients will be given a detailed examination and a treatment plan.

Patient Details

Referring Details

The CBCT image will be reported on by the referring dentist as per your service level agreement - we can arrange for an outside source to report on findings at an additional cost. Important information: it is essential that you complete all sections of this form in full. All incomplete forms will be returned to the referring dental practice, which may result in a delay in your patients’ treatment. The referring practice will be responsible for ensuring the clinical evaluation takes place and is properly recorded.

Signature of referring dentist

Click or drag a file to this area to upload.


If you do not have a digital version of your signature available please type name in box above and check the box below to acknowledge the inclusion of all data required for us to proceed