CBCT Imaging referral form Reffering Practioner Referring Colleague Name* Referring Colleague Email* Referring Colleague Address* Referring Colleague Tel. No.* Patient Details Patient Name* Patient D.O.B. Patient Tel.No.* Patient Email (If known) Patient Address* Reason for referral The clinical context for requesting a dental CBCT examination What information do you want the dental CBCT examination to provide? Define the anatomical area that the scan should cover?