X-Ray & CBCT Scan Online Referral form at The Dental Gallery, Ealing

Referring Dentist Details

Your details

Tell us who you are

Title

First Name

Last Name

Practice Name

GDC Number

Your Email

Your 2nd Email (if applicable)

Your Phone Number

Your 2nd Phone Number (if applicable)

Your Address

Postcode

City

Country

Patient details

Tell us the patients details

Patient Title

Patient First Name

Patient Last Name

Patient DOB

Patient Gender

Male Female

Patient's Email

Patients Primary Number

Patients Secondary Number

Patient's Address

Postcode

City

Country

Examination Required

Digital OPG X-ray Digital Cephalometric X-ray Cone Beam CT Scan My patient will wear a stent

Which teeth? (if applicable)

Is the patient coming with a radiographic template?

Yes No

1. Upload X-Ray / Images

2. Upload X-Ray / Images

Justification for Imaging

Clinical Information

Medical History

Patient appointment preferences

CBCT
The following section is only required for CBCT patients

CBCT Area of Interest

Is the patient coming with a radiographic template?

Low Dose CBCT?

(usually used for post-op scans as lower resolution)

Date appointment is needed

Acceptance

I confirm by submitting this form that I am a registered dentist and I understand that in the case of X-ray referrals, a report will not be provided and will have to be arranged by myself.