Please fill out the form below. "*" indicates required fields Referring Dentist DetailsReferring Dentists Name* Practice Name* Telephone*Email* Patient DetailsPatient Name* Patient DOB* DD slash MM slash YYYY Patient Telephone*Patient Email* Patient Address*Scan DetailsType of Scan*- Please Select -Cone Beam CT - mandible 8x8Cone Beam CT - maxilla 8x8Cone Beam CT - sextant 5.5 x 5OPTReason for Scan*PLEASE SPECIFY TEETH/AREAS TO BE SCANNEDIs there a stent to be fitted?*- Please Select -YesNoFormat Required*- Please Select -with viewing softwarethird party software compatibleHow would you like to receive the scan?- please select -on a discelectronicallyReporting*- Please Select -Please provide the scan with a reportI will provide my own reportI have advised my patient of the following fees (payable at the time of the scan) Scan without report €190 5.5 x 5 Scan with Report €280 8 x 8 Scan with Report €280 Please Note To comply with IMER 2000 & IRR 2018 regulations all radiographs and scans must be reviewed and reported into the clinical records by the referring practitioner or by an appropriately trained individual. We strongly recommend that all scans and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology. If the referring practitioner prefers that they make their own arrangements for the reporting, please let us know in advance.How did you hear about us?* Marketing Consent I agree to receiving marketing and promotional materials
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