CT Scan referral form

Download Printable Version

Dental Cone Beam CT Scan Request Form
  • Patient Details

  • Referring Dentist Details

  • CT Scan details

    All scans will be parallel to the occlusal plane unless otherwise specified.
  • CT Scan Charges

    Scan including radiologist’s report £280.00
    Nobel guide radiographic index scan £50.00
  • This field is for validation purposes and should be left unchanged.