Martock Dental Practice

OPG/CBCT Referrals

OPG/CBCT referrals are welcome

We are proud to announce, we now offer OPT/ CBCT imaging to our existing and new clients on a referral basis. Once you fill out the below referral form, the images will be sent to you via your registered email address.

Please fill out as much information as possible below to help us help your patients!

Patient Details

Patient Name *

GDC Number *

Address

Address Line 1

City

County

Post Code

Referral Type

Date of Birth *

Phone

Patient Email *

Relevant Medical History

Referral Information

Type of X-ray/CBCT required *

CBCT
Full OPG
Partial OBG
Extra Oral BW’s

Reason for referral

Planned Treatment

Referrer Details

Referrer Name *

Referrer Email *

Referrer/ Practice telephone

Practice Name *

GDC number

Martock Dental Practice

OPG/CBCT Referrals