OPT & CBCT Referral form

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Practice Details

Referring dentist:

Referring practice

Practice contact tel:

Practice contact email: (this will be the receiving address for radiograph) *

Patient Details

Patient title

Patient Name *

First

Last

Patient Date of Birth

Patient gender

Male
Female

Patient First Line of Address *

Patient Second Line of Address

Patient Town / City

Patient Postcode

Patient Best Contact Number

Patient Email

The patient will receive a link to complete a medical history via an online portal

Investigation Request

I am referring the patient for (check as appropriate)

OPT
CBCT 5x5
CBCT 8x5

(CBCT 5x5 is usually indicated for maxilla OR mandible, CBCT 8x5 is indicated for maxilla AND mandible)

Teeth / area to be included on OPT / CBCT:

Layout

Clinical indication:

We will return all CBCT scans as dicom files and OPTs as jpeg. Both will be sent via email. If you would prefer another format, please call us on 01298 27077 to see if we can arrange this

Justification (please check as appropriate)

Implants
Endodontics
Orthodontics
Impacted teeth
Bone Grafts
Oral Pathology

Price List:
OPT £70
8x5 CBCT £175
5x5 CBCT £145
Consultant radiologist CBCT report 5x5 £80
Consultant radiologist CBCT report 8x5 £100
*Please be aware that you require a Service Level Agreement with Lightwood Dental to be able to refer for CBCT.
Please email practicemanager@lightwooddental.co.uk to arrange this with us

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