CT-Scan Referral in Downing | Precise Diagnostic Imaging

CT-Scan Referral

Please fill in the form below to provide information about the CT Scan Referral.

First Name

Last Name

Telephone

Date of Birth

Patient Address

Name of Dentist

Dentist’s Phone Number

Practice Postcode

Referring Dentist Email Address

Referrer GDC Number

Practice Address

Confirm Irmer Referrer Training *

Yes

Region to be Scanned *

Region to be Scanned

Reason for Referral and Justification for the scan

Special Instructions to IRMER operator involved in scan acquisition

Treatment Costs

Treatment Costs *

£95 for all CBCTS

NOTE : CT-Scan files will be sent to the patient as a compressed file.

Acceptance *

I consent to my data being used in accordance to the Privacy Policy.