CT Referral Form

01234 348899
reception@latchfordandlatchford.co.uk
49 Castle Road Bedford MK40 3PL
Accepting New Patients & Specialist Referrals

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Dental Referral Form

Please complete the form below in full and submit. We will contact your patient for an appointment.

Patients Details

Patients Name *

Patient Address *

Patient DOB *

Patient Home Telephone

Patient Work/Mobile

Patient Email

Patient Comments

Referrer Details

Referrer Name *

Referrer Surgery

Referrer Address

Referrer Telephone

Referrer Email

Scan Details

Area to be scanned *

Maxilla
Mandible

Clinical Information

Reason for scan

Scan Fee £120 *

4cm x 4cm scan area
8cm x 8cm scan area

4cm x 4cm Scan

Covers smaller areas e.g. wisdom teeth, TMJ’s, unerupted canines and cysts.

8cm x 8cm Scan

Covers whole mandible and maxilla. Suitable for assessment of bone levels and nerve position prior to implant surgery.

The images are forwarded for reporting by the referring practitioner on a memory stick. We are pleased to assist in opening the files on the practitioner’s own computer.

Digital Signature *

Digital Signature Date

Name

Data Protection

We take your and the privacy of our patients very seriously and have policies, procedures and the infrastructure in place to protect any information and documents provided to us. We are fully complaint with the GDPR legislation and other applicable data protection regulations. For more information, please click here to view our full privacy policy.