Referring Dentist Details
    Patient Details

    Referral for:

    Implant assessment
    Implant placement no restoration
    Implant placement and restoration
    Full arch implant bridge
    Full-mouth rehabilitation
    Aesthetic dentistry
    Removable prosthodontics
    Tooth wear
    CBCT scan
    OPG scan


    Complete if referring for CBCT

    In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.

    Note: we are able to recommend the services of a specialist in Oral and Maxillofacial radiology should you wish to arrange a radiographic report. Please visit for more information.

    On submitting your referral you agree to our privacy policy and consent to the collection of personal data. All personal data submitted via this form, including your scan (which will be shared with you using our secure imaging server ‘360cloud’), will be stored and used in line with the General Data Protection Regulation (GDPR).

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