Treatment Required

ImplantsOral SurgeryInvisalignRoot CanalCBCTOPGOther

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Please fill in the full details of the treatment requested / Justification for the radiograph / Area of interest (mandatory)

(If no teeth are selected the whole jaw will be scanned)

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Patient Details

D.O.B.

Is there a possibility of pregnancy for
OPG/CBCT? (Mandatory)
YesNo

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Referring Dentist

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Please state what has been enclosed
X-RaysMedical History SheetOtherCastsAre they bringing own Radiographic template?

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Upload any Radiographs, pictures or documents here

*By Sending this referral form you agree to our Standard T&C