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 2QUTel: 01707 524 442 Our Fees: CBCT: £95OPG: £45 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 Panoramic X-ray (OPG) Cone Beam CT Area of Interest (CBCT Only) Area of Interest Full Upper Full Lower Full Upper and Lower Single tooth or 2 adjacent teeth Clinical Indications (Justification for the Radiograph) Who is Paying for the Scan? Who is paying scan The Referring Practice The Patient Please Sign Below by Retyping Your Name Signaturename Consent I consent to my personal data being collected as per our Privacy Policy* Send