OPG / CBCT Scanning at Cornwall Implant Centre

CBCT Scanning Referral Form

Name of Referring Dentist *

Practice Name *

Practice Address *

Postcode *

Contact Tel Number *

Patient’s Full Name *

Title * MrMrsMsMiss

Date of Birth *

Address *

Postcode *

Home Tel

Mobile *

Email Address

Present Dental Condition *

Medical History *

Reason for scan *

OPG

CBCT Dual Jaw

CBCT Single Jaw - Upper

CBCT Single Jaw - Lower

CBCT - Tooth Specific (please specify)

Any other details:

0 + 4 = ? Please prove that you are human by solving the equation *