IMAGING REFERRAL FORM

Referred by:

Name : Surname :
Address:
Telephone: Email:

Patient Details:

Title : Surname : Forename :
Address:
DOB: Telephone: Mobile:
Email:

Radiographic Examination Required:

       
DPT Or Cone Beam CT  

 

For Cone Beam CT image please tick one of the following boxes:

 

 
Both Jaws Upper Jaw Lower Jaw Small Volume
(Collimated to Sextant of Interest)
       
       

Describe Region of Interest / Purpose and Justification for Examination:

Cone Beam CT Data Format: (Please Tick One)

Sicat View:
(No Additional Fee)
Simplant View:
(Additional Fee Applies)
   
Simplant One Shot:
(Additional Fee Applies)
Simplant Planner:
(Requires Software Licence from Materialise)
   

Payment

Account to Referrer Or Patient to Pay

The SmileSuite does not routinely report upon scans and radiographs for patients who are referred to us for dental imaging. To comply with IRMER 2000 regulations all radiographs and scans are required to be reported by the referring practitioner or by a radiologist.

Name of Referrer: Date:
       
The Smile Suite - Award Winning Bristol Orthodontics

Appointments

Tel: 0117 974 6550

Email: info@thesmilesuite.com

Opening Hours

Monday 8.00am - 4.30pm
Tuesday 8.00am - 8.00pm
Wednesday 8.00am - 6.45pm
Thursday 8.00am - 4.30pm
Friday 8.00am - 1.45pm
Weekends Closed
Bank Holidays Closed