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Refer a patient to Apolline Dental
CT Referral
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Apolline Dental
2a Buxton Road
Chingford
London
E4 7DP
CALL 020 8529 1422
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020 8529 1422
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CT Referral
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CT Referral
Referring dentists details
Dentist name
(Required)
Dentist phone
(Required)
Dentist email
(Required)
Dentist address
(Required)
Dentist post code
(Required)
Patient details
Patient Name
(Required)
Patient Phone
(Required)
Patient Email
(Required)
Patient date of birth
(Required)
MM slash DD slash YYYY
Untitled
(Required)
Patient Post Code
(Required)
Clinical context for requesting the scan
(Required)
Relevant medical history
(Required)
What information do you want the radiographic examination to provide?
Type of radiograph requested
Panoramic
Cephalometric
Dental CBCT
Justification of scan
Implants
Bone graft
Orthodontics
Impacted teeth
Endodontics
TMJ
Oral pathology
Define the anatomical area that the radiograph/scan should cover
(Required)
Account settled by
Patient
Dentist
File upload of a radiograph or photo
Drop files here or
Select files
Max. file size: 10 MB, Max. files: 8.
Consent
I confirm that the referring practitioner is a GDC registered dentist, who has the appropriate training as required by CQC & GDC to request this scan.
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