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Dental Implant Extractions CBCT

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Home ReferralsCBCT

Dental Implant Referral Form Extractions Referral Form CBCT Referral Form

CBCT Referral Form

Please complete the form below and we will contact the patient as soon as possible:

Referring Dentist Details

Referring Dentist:*

Practice Name:*

Practice Address 1:*

Practice Address 2:*

Practice Postcode:*

Practice Phone Number:*

Practice Email:*

Reasons for Scan*

Implants

Ortho

Impacted Teeth

Endodontics

Sinus Exam

Patient Details

Patient Name:*

Telephone:*

Mobile:*

Email:*

Date of Birth:*

Relevant Medical History*

Areas of Intrest

Dual Jaw

Mandible

Maxilla

Small Field 5x5

True 2D OPG

Area of Interest*(please enter numbers separated by commas)

Reporting

IRMER 2017 Regulations: We do not routinely report upon referred scans or radiographs. To comply with the IRMER 2017 Regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. We strongly recommend that all CT and other radiographic examinations should be reported upon to rule out the possibility of co-incidental pathology.

By not ticking this box I am happy to make my own arrangements.

Reporting (Tick if Yes)

Special Instructions*

Signature (Type Name):

Date 01/03/2026

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Regent Dental Ltd trading as Regent Dental is an Appointed Representative of Chrysalis Finance Limited, which is authorised and regulated by the Financial Conduct Authority. Regent Dental Ltd is a credit broker, not a lender. The provider of a payment scheme which is not offered through or by Chrysalis Finance Limited may not be so authorised and regulated.

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