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The-Smile-Suite-Award-Wining-Orthodontics Welcome to our
luxurious specialist, implant & referral centre

Imaging referral form:

Patient details:

dd/mm/yyyy

Patient address:

Referring dentist:

Dentist address:

Radiographic Examination Required:

Choose

For Cone Beam CT image please tick one of the following boxes:



Describe Region of Interest / Purpose and Justification for Examination:

Cone Beam CT Data Format:

Choose one



Payment

Choose one

The SmileSuite does not routinely report upon scans and radiographs for patients who are referred to us for dental imaging. To comply with IRMER 2000 regulations all radiographs and scans are required to be reported by the referring practitioner or by a radiologist.