Patient Referral Form

    Treatment Required

    Please tick and specify details below in the box provided.


    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 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.

    Referrer Details

    Additional Details For CT Scan Request

    Examination Required (Parallel to occlusal plane unless requested otherwise)

    Patient to wear stent provided by own dentist?

    Format Required by Dentist

    With Free Viewing software on Disc:

    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

    (Click to read guidance notes)