Online Referral – CBCT/OPT Order Number Referring Dentist Details Dentist Name: * Practice Name: * Practice Address: * Email Address: * Patient Details Title: * First Name: * Last Name: * Address: * Date of Birth: * Phone Number: * Email Address: Relevant Medical History: Drugs: Allergies: Required Scan: * Digital OPT - £29 CBCT Scan - Maxilla - £95 CBCT Scan - Mandible - £95 CBCT Scan - Both Jaws - £125 CBCT Scan - Sextant - £85 If sextant, please indicate teeth range: Reporting: * Referring clinician will undertake reporting Consultant Radiologist Report Required Radiologist Fees; OPT - £50 CBCT Sextant - £50 CBCT Single Jaw - £80 CBCT Both Jaws - £100 Justification: * Additional Information (Optional): Payment: * Patient to Pay Invoice Practice Information Summary
