Dental CT Scan or OPG Referral Form

Dentists - Please Fill-in the Form

*In-house CT Scanner at AJ Dental Care in Potters Bar. CT Scan & OPG Hertfordshire Referrals.

AJ Dental Care: 28 Barnet Rd, Potters Bar, EN6 2QU
Tel: 01707 524 442

Referring Practitioner / Clinic Details

Referrer's Full Name

Dental Practice Name*

Dental Practice Address*

Dental Practice Post Code*

Practice Phone Number*

Practice Email*

Date of referral*

Patient Details

Patient Name*

Patient Date of Birth*

Patient Address*

Patient Post Code*

Patient Email*

Patient Mobile Telephone*

Examination Required (CBCT or OPG?)

Examination Required

Area of Interest (CBCT Only)

Area of Interest

Clinical Indications (Justification for the Radiograph)

Who is Paying for the Scan?

Who is paying scan

Please Sign Below by Retyping Your Name

Signaturename