Imaging Referral Form

Referred by:

Patient Details:

  • Date of birth
  • Possibility of pregnancy

Examination Required

    • Digital Panoramic
    • Cone Beam CT Parallel to occlusal plane / lower border / palate
    • My patient will wear a stent

Upper Right

Upper Left

Lower Right

Lower Left

  • Region of Interest:

    • Lower jaw
    • Upper jaw
    • Right TMJ
    • Left TMJ
    • Full height
    • Dental Small Volume
    • Full height
    • Maxillary Sinus
    • Frontal Sinus
  • Package:

    • “Scan + Anatomical Model”
    • “Scan + Dental Implant Planning”

Software Options for Cone Beam CT Scans

    • CT Viewer
    • DICOM for Mac Users
    • DICOM for i-Dent
    • Nobel Clinician Viewer
    • Please contact me to discuss options

Delivery Options

    • CD (Post)
    • CD (Patient)
    • USB (Post)
    • USB (Patient)

The White Bridge Dental Practice does not routinely report upon scans and radiographs. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into clinical notes by recommends that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. The White Bridge Dental Practice offers a reporting service by a Consultant Radiologist.

    • I would like this patient’s radiographic examination to be reported upon by your Consultation Radiologist. (£125 charge)
    • I will make my own reporting arrangements.

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Services

We offer a wide range of dental treatments.

More Information
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140 Oxford Road, Kidlington, OX5 1DZ
01865 951861 info@thewhitebridgeclinic.co.uk
Opening Hours
Day
Hours
Monday
9:00am – 5.30pm
Tuesday
9:00am – 6.15pm
Wednesday
9:00am -5.30pm
Thursday
9:00am – 5.30pm
Friday
9:00am – 4.30pm
Saturday
9:00am – 4.30pm

Fast train links into London, on site parking & disabled access