Referrals

Investigation(s) Requested*

CBCT Scan

OPT

Lateral Cephalometric Radiograph

Reason for Investigation(s) e.g. Implant/Ortho*

Region of Interest (if applicable) eg. Mandible or UL

Special Instructions e.g. Radiographic Template

Possibility of Pregnancy?

Yes

No

Output*

Email (Download Link)

Memory Stick

CD

Patient Title

Patient Surname*

Patient Forename(s)*

Patient Date of Birth*

Patient Contact Number*

Patient Email

Patient Address

Referring Practitioner Name*

Referring Practitioner Email*

Refer a Patient to UK Smile