CBCT Scan/OPT Referral | Prestwichdental

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Patient Name*

Date of Birth*

Day

Month

Year

Email*

Contact number*

Is the patient pregnant?*

Yes

No

Dentist's name*

Dental Practice address*

Dentist's Email*

CBCT scan required?*

Sectional

Full Maxilla

Full mandible

Both Jaws

Quadrant

OPT (panoramic) only

If Sectional or Quadrant, which tooth/area?*

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Patient

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