CBCT Referral Form Please fill in the referral form below to submit a referral. Alternatively, you can download our PDF form, fill it, and return to firstname.lastname@example.org Referrer DetailsName of Referrer*GDC Number*Practice Name*Phone Number*Email* Address* Street Address City ZIP / Postal Code Patient DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Date of Birth* Phone Number*Email Relevant Medical HistoryPossibility of pregnancy*YesNoScan DetailsHow would you like to receive the scan?*DropboxUSBHas the patient been informed of the cost of the scan?*YesNoIs the patient coming with a radiographic stent?*YesNoWhich areas would you like the scan to cover?(If no areas have been selected then both arches will be scanned i.e. 110 x 80 mm) Mandible Maxilla Both Jaws Whole Sinuses Floor of Sinus Only Upper Right UR8 UR7 UR6 UR5 UR4 UR3 UR2 UR1 Upper Left UL1 UL2 UL3 UL4 UL5 UL6 UL7 UL8 Lower Right LR8 LR7 LR6 LR5 LR4 LR3 LR2 UR1 Lower Left LL1 LL2 LL3 LL4 LL5 LL6 LL7 LL8 Please select a scan size(If known) 40 x 40 mm 60 x 60 mm 80 x 80 mm 1100 x 80 mm Would you like our radiologist to write a radiology report of the scan (£85)?*YesNoTo comply with Irmer 2000 regulations, all CBCT scans are required to be reviewed and reportedJustification for scan* Implants Bone Graft Periodontal Assessment Post-Op Low Dose Endodontics Sinus Examination TMJ Assessment Oral Pathology Impacted Teeth Orthodontics Other Other*Please give more detailsUpload documentsPlease attach any radiographs or documents that may be useful to us here. Maximum file size is 32MB, to upload larger files, please contact us at email@example.com Drop files here or Submitted by*I confirm that I have received the necessary training to make this referralDate of Referral* CaptchaEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.