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CBCT Referral Form

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Referral Form

- Step 1 of 4

Referred By

Referred By

Practice Email *

Clinician's Name *

GDC / GMC Number *

Practice Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Practice Telelephone

Referral Date

Patient Details

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Contact Tel *

Date of Birth *

Possibility of Pregnancy *

Yes
No

Billing Options

Patient to Pay
Referrer to Pay

Examination Required (Options)

Examination Required

Cone Beam CT - £180 (both jaws) - £95 (single jaw or small volume)
OTP - £60
Radiologist Report (£120 - 7 working days required)

Examination Required

Both Jaws
Full Upper Jaw
Full Lower Jaw
Small Volume

Justification for exposure *

IR (ME)R Regulations : To comply, all radiographs must be clinically evaluated to rule out the possibility of coincidental pathology. Westbury Dental Care does not routinely report on dental scans or x-rays; by referring for dental imaging, the referrer accepts the responsibility for arranging reporting. Alternatively, Westbury Dental Care offers a radiology reporting service on request

Westbury Dental Care

75 Kingston Rd, New Malden, KT3 3PB T: 020 8942 8943 E: info@westburydentalcare.com

Additional Information

Relevant Clinical Details

Relevant Medical History

Radiographs

Yes
No

CBCT

Yes
No

Photographs

Yes
No

Study Modules

Yes
No

Please send by email / post / USB/ Printed where applicable

Would referring dentist like mentorship with the case or like to be present at time of treatment

Yes
No

By confirming this form submission you are agreeing to our Privacy Policy.

Westbury Dental Care

75 Kingston Rd,
New Malden,
KT3 3PB

T: 020 8942 8943
E: info@westburydentalcare.com

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Dental Appointments

Monday 9 am – 6 pm
Tuesday 9 am – 6 pm
Wednesday 9 am – 6 pm
Thursday 9 am – 6 pm
Friday 9 am – 5 pm
Saturday*9 am – 5 pm

Hygienist Appointments

Monday 9 am – 2 pm
Tuesday 9 am – 5 pm
Wednesday 9 am – 5 pm
Thursday 9 am – 2 pm
Saturday*9 am – 5 pm

Saturday appointments available for patients receiving private treatment only

Practice closed on all Bank Holidays