CBCT/OPG Referral Form – The Temple Practice

Consent & Medical History Form

"*" indicates required fields

Step 1 - Patient Details

Patient Name*

Title First Surname

Patient Address*

Street Address Address Line 2 City County Post Code

Patient Email*

Patient Phone Number*

Patient Date of Birth*

Step 2 - Referring Dentist's Details

Name of Dentist*

Practice Name*

Dentist's Practice Address*

Street Address Address Line 2 City County Post Code

Dentist's Email*

Dentist's Phone Number*

Step 3 - Referral Details

Please confirm you are permitted to prescribe a OPG/CBCT Scan*

Yes

Reason for referral and justification for OPG/CBCT Scan*

Relevant Dental History*

All OPG/CBCT scans will be supplied via a secure link

File Attachment

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.

Any Other Comments

For information about how we will use your personal details please see our Privacy Notice

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Consent & Medical History Form

Step 1 - Patient Details

Step 2 - Referring Dentist's Details

Step 3 - Referral Details

You are now in a secure area