Treatment Required

Please tick and specify details below in the box provided.

Laser Supported Dental ImplantsLaser Supported Oral SurgeryLaser Supported Endodontics-PIPSLaser Supported PeriodonticsCT Scan (complete details below)OPG (Panoramic radiograph)Other

Enclosures

Please tick the supporting material you will be posting us. If you have any relevant radiographs, please so send them preferably by email. Enclosures can also be emailed to smile@onclinic.co.uk under separate cover. If emailing attachments (e.g. X-rays), as it will be non-secure, please omit patient's name but add the following details in the subject line: Patients initials, Patients Date of Birth, Referring Dentists Name.

X-raysStudy CastsCovering Letter

Referrer Details

Additional Details For CT Scan Request

Examination Required (Parallel to occlusal plane unless requested otherwise)

CT MaxillaCT MandibleCT of both jawsPlease tick if you would like CT Maxilla to show 20+mm maxillary sinu (eg prior to sinus lift)

Patient to wear stent provided by own dentist?

Please SelectYesNo

Format Required by Dentist

With Free Viewing software on Disc:

Single window £135Single jaw £150Both jaws £210

Please contact us to discuss other formats/software licence fees etc if required.
Scans are normally delivered within 7-10 days. Additional information on request.

Please tick if requesting a CT scan

I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer / Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (Click to read guidance notes)