Referral Form – Cottage Dental & Implant Clinic

01793 855335
8 High Street, Royal Wootton Bassett, Swindon, SN4 7AA
info@cottageimplantclinic.co.uk

CBCT Referral Form for Dentists

Refer patients to us for CBCT scans using the latest technology, towards planning of Dental Implant Cases.

Download the form as PDF or fill in the form below

REFERRER DETAILS

Date of Referral

Upload up to 5x File/Image (Up to 8MB each)*

WHO IS REFERRING*

Practice Owner Practice Manager Staff Member Nurse Patient

PATIENT DETAILS

Gender*

Male Female

Possibility of pregnancy?*

Yes No

Area of Interest:

Both Jaws (8 x 8cm) Maxilla (8 x 5cm) Mandible (8 x 5cm) Quadrant (5 x 5cm)

Patient to bring radiographic template?

Yes No

Radiographic Template Type:

Denture Marked Separate Template

Justification for CBCT:

Implants Endodontics Sinus Exam TMJ Oral Pathology Bone Graft Orthodontics Impacted Teeth

CBCT Format:

DICOM Files Romexis Viewer

CBCT Output*:

CD-ROM Email

Digital impression required? (STL file - additional £10):

Yes No

2-D Digital Panoramic (OPG) required:

Yes No

2-D Output:

Yes No

Dose Reduction Required?

Yes No

I consent to my personal data being collected as per our Privacy Policy*