FOR SELF AND PROFESSIONAL REFERRALS XRAYS & CBCT REFERRAL FORM Dentist or Self Referral?(Required) Dentist Referral Self Referral Referring ProfessionalType of scan(Required)Choose a scan typePanoramic radiograph (OPT)3D CBCT Scan (small field)3D CBCT Scan (maxilla)3D CBCT Scan Single Arch (Mandible)3D CBCT Scan (Dual Arch)3D CBCT Scan (Endo)3D CBCT scan (TMJ)3D CBCT Scan (Maxillary Sinuses)3D CBCT Scan (Wisdom teeth)Name of practice(Required) Name of dental professional*(Required) Practice Address(Required) Postcode(Required) GDC Number(Required) Telephone(Required) Email Address(Required) Patient DetailsType of scan(Required)Choose a scan typePanoramic radiograph (OPT)3D CBCT Scan (small field)3D CBCT Scan (maxilla)3D CBCT Scan Single Arch (Mandible)3D CBCT Scan (Dual Arch)3D CBCT Scan (Endo)3D CBCT scan (TMJ)3D CBCT Scan (Maxillary Sinuses)3D CBCT Scan (Wisdom teeth)TitleTitleMrMrsMissMsFull Name(Required) Date of Birth(Required) Email Address(Required) Address(Required) Postcode(Required) Telephone(Required) ReasonChoose Files Drop files here or Select files Accepted file types: jpg, jpeg, pdf, doc, exc, xls, docx, Max. file size: 128 MB. Are any images to include? Please attach up to 5 files below. Please include any additional related documents (Excel, Word, etc)