Tel: 0117 9238 400 Fax: 0117 9467 007 Email: info@rootfillings.com

3D CT Scan - Make a referral

Please note the referrals page is for use by the dental profession only.

Please fill in the form and click on the 'Send Referral' button to send the information electronically to us.

Patient information
Patient name:
Address:
Date of birth:
Home telephone:
Work telephone:
Mobile telephone:
(Needed for SMS updates)
Email:
Contact via?
Dentist information
Referring dentist:
Address:
Telephone:
Fax:
Email:
Reason for referral:
GDC number:
GMC number:
CT scan required:
Maxilla
Mandible
Tooth number:
CT scan charges:
Scan on single jaw (£120.00)
Scan on double jaw (£200.00)
Radiologist report (£80.00)
Please indicate your preference for radiological interpretation of the dento-alveolar region:
Please supply a Consultant Radiologist report
I undertake to report on the scan myself as required by IR(ME)R 2000/2006
Before clicking 'Send Referral', please ensure that a valid email address has been entered in the dentist 'Email' field above. This is so that we can send you confirmation that the referral has been sent.

Patient information