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Smilers
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CBCT / OPG Referral
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Contact Us
About Us
Meet the Team
Treatments
General Dentistry
Cosmetic Dentistry
Dental Implants
Epic Laser Dentistry
Smilers
Direct Access Hygieniests
Perio Care
NHS Dental Care
Mouth Cancer Screening
Concentrated Growth Factors (CGF)
Oral Surgery
Dental Anxiety
New Patient Registration
Dentist Referral
Implant Referral
IV Sedation Referral
CBCT / OPG Referral
Fees
Testimonials
FAQ
Contact Us
Book an Appointment
About Us
Meet the Team
Treatments
General Dentistry
Cosmetic Dentistry
Dental Implants
Epic Dentist
Smilers
Direct Access Hygieniests
Perio Care
NHS Dental Care
Mouth Cancer Screening
Concentrated Growth Factors (CGF)
Oral Surgery
Dental Anxiety
New Patient Registration
Dentist Referral
Fees
Testimonials
Contact Us
FAQ
Book an Appointment
About Us
Meet the Team
Treatments
General Dentistry
Cosmetic Dentistry
Dental Implants
Epic Dentist
Smilers
Direct Access Hygieniests
Perio Care
NHS Dental Care
Mouth Cancer Screening
Concentrated Growth Factors (CGF)
Oral Surgery
Dental Anxiety
New Patient Registration
Dentist Referral
Fees
Testimonials
Contact Us
FAQ
Book an Appointment
CBCT / OPG Referral
Step
1
of
2
50%
Dentist Name
(Required)
GDC Number
(Required)
Practice Name
(Required)
Practice Address
(Required)
Address Line 1
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Telephone
(Required)
Contact Email
(Required)
Patient Name
(Required)
First
Last
Patient DOB
(Required)
MM slash DD slash YYYY
Patient Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
(Required)
Email
(Required)
Medical History
(Required)
Patient possibly pregnant?
(Required)
Yes
No
Dental History
(Required)
Referral Type
(Required)
CBCT
OPG
Reason for referral and justification for the scan
(Required)
CBCT areas of interest
Mandible
Maxilla
Both Jaws
Disclaimer
(Required)
In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans. *
Disclaimer
(Required)
I fully understand that East Calder Smile Centre does not report on scans or OPGS and it is the referring dentists responsibility to arrange this.
Please confirm if radiographic stent is required for CBCT
(Required)
Yes
No
Special instruction/ Further Notes
Please note images will be sent via email. What is your preferred email address to send scan to?
(Required)
Referrals and Appointment Booking
Appointment booking requests must be accompanied by a fully completed referral form. Referrals will be rejected if the referral form is missing or incomplete. It is the responsibility of the Referring Practice to ensure that referral forms are received at least 48 hours prior to the scheduled appointment time.
Please let your patient know the cost of the CBCT is 125£ and will be taken at time of booking
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