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CBCT & OPG Referral

Complete the referral form below to refer your patient for CBCT or OPG imaging at Supernova Dental.

Please fill in the CBCT/OPG form below

Referring Practice Details

Patient Details

Referral Requirements:

The referring clinician is responsible for supplying us sufficient information to justify an appropriate exposure. We request all parts of this form to be completed in advance to avoid any delay arranging the patients appointment.

0 / 500 characters
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2D field of view required (OPG):

3D field of view (CBCT): For CBCT referrals, if an intra-oral radiograph of the area is available please attach it for justification purposes.

8x8cm:

11x10cm:

Exposure: Standard image resolution will be used unless you specifically request high or low resolution.

Radiographic stent to be worn:

Declaration: By completing below, you declare that you:

Unless otherwise specified the image data will be supplied in DICOM format. The Acteon Imaging Software (compatible with Windows) will be included in the file. Files will be password protected and sent to the e-mail provided via WeTransfer.

This confidential form provides us with the information we require to receive a patient referral. The information contained within this form should be true and accurate to the best of your knowledge and with the patients consent. By submitting this form, we will securely collect yours and your patients details. We will then store and process this information in accordance with our Privacy Policy.