Referral Form Fields marked with an * are required Dentist Details Dentist Details Dentist Name * Dentist Phone Number * Dentist Email * Dentist Address * Dentist Postcode * Patient Details Patient Details Patient First Name * Patient Last Name * Patient Phone * Patient Date Of Birth * Patient Address Patient Postcode * Referral Details Referral Details Purpose of the referral * Relevant Medical History * Justification of x-ray * Implants Bone graft Orthodontics Impacted teeth Endodontics TMJ Oral pathology Field Required * Partial Field (3-4 Teeth) - £200 Full Maxilla - £200 Full Mandible - £200 Full Maxilla and Mandible - £200 Dental OPT - £95 Optional radiographic report required? (£110.00) * Yes No Implant Surgical Guide (£150.00) * Yes No Implant Planning (£85.00) * Yes No Account Settled by? * Patient Dentist I confirm that I have taken a medical history for the patient. I can also confirm that (if the patient is female), she is not pregnant. * Please Note We do not accept your patients for treatment. Patients remain in your genral care. Nottingham ConeBeam does not report upon scans and radiographs provided for referring dentists. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical records by the referring practitioner or by a radiologist. We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. Your 3D Scan will be delivered by post on a CD with a free viewing software. 2d X-rays can be delivered by email.' If you are a human seeing this field, please leave it empty.
