Referring Dentist & GDC No: Patients Name:
Practice Name & Address:

Practice Tel No: DOB:
Practice Email: Tel No:
Referring Dentist ID NoBefore submitting a referral please contact us for your Referring Dentist ID no

Digital OPT Request
Full mouth RHS only LHS only TMJ included

Low Dose CBVT (3D Scan)
Both Arches
Upper only
Lower only
HD image required: YES    NO
CBVT Image Format:
   Galaxis (generic default)
Alternatively select the area of Interest :

Upper right
Upper left
Upper central

Lower central
Lower right
Lower left

Guided Surgery Only

Is the radiograph stent included? Yes      No

Clinical Justification; Any Other Comments:

*Please note that our team at Quadrant Dental Practice will NOT report on scans on behalf of referring practitioner. In keeping with IRMER 200 Regulations we must remind you that ALL radiographs/scans MUST be reviewed and findings noted in your patient's clinical notes by referring practitioner or by a consultant radiographer. (Please contact Quadrant Dental Practice for further information if required)