External Referral

new patient

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New Patient
New Patient
New Patient
CBCT Form

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Name of Referrer*:

Practice Name*:

Email*:

Telephone*:

Address*:

Name of Patient*:

Date of Birth*:

Address*:

Telephone*:

CLINICAL INDICATIONS (Please Complete)* :

Is the patient coming with Radiographic Stent*:

Is the patient possibly pregnant?*:

PAYMENT BY*:

COST: CBCT Single Arch £150, CBCT Both Arches £300, iTero Scan both Arches £150

Please select your preferred CBCT format*:

File delivery options*:


Note: Bluebell Dental Practice and Clinic do not routinely report on CBCT scans. To comply with the IRMER 2000 regulations all CBCT scans are required to be reviewed and reported in the clinical notes by the referring practitioner or by a radiologist.


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Opinion only Opinion & treatment
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(Please attach as a image(jpeg,jpg format), file size no greater than 1MB)