Referral for CBCT / DPT

Patient details

First Name

Last Name

Date of birth

Address

Postcode

Enter Mobile Number

Enter Email ID

Referring Dentist details

First Name

Last Name

Practice

Address

Postcode

Enter Mobile Number

Enter Email ID

Required Image/Scan

Required Image/ Scan: (please tick)

DPT (Cost £60) CBCT (£100 per scan without report)

Justification for scan