01376 501688
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2 Maldon Rd, Witham, Essex
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Imaging
Referrals
For the referral of patients for Dental CBCT & Panoramic Radiography examinations
Please enable JavaScript in your browser to complete this form.
Patient Name
*
First
Last
Patient Telephone Number
*
Patient Address
Patient date of birth (DOB)
Relevant medical history:
Other relevant information & brief treatment history:
Has the patient been informed of the cost of the scan
Yes
No
If not, is this because the practice is paying for the scan?
Yes
No
Xrays uploaded (will be uploader on live site)
Referring Dentist Name
*
Referring Dentist Email
*
Referring Dentist Practice Telephone Number
*
Referring Practice Address
Date of Referral
I am the IRMER referrer & operator. I am adequately trained to report on my patients scan
Yes
No
Type of radiograph
Panoramic (OPG)
Dental CBCT
Clinical context for requesting the above examination:
Relevant results of history, clinical examination and other imaging:
What information do you want the radiographic examination to provide?
Define the anatomical area that the radiograph should cover:
Intra-oral scans/clinical photos
Click or drag files to this area to upload.
You can upload up to 5 files.
Maximum file size 3MB per file
Submit
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Blake Dental
2 Maldon Rd, Witham, Essex, CM8 2AB
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01376 501688
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Blake Dental Ltd. Registered in England and Wales with company number 13142208
Site last updated June 2024
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