OPG and CBCT Referral to Treeline Dental Care

Patient Details

Please complete the below patient information.

Referring Dentist Details

Please complete the below referring dentist information.

Referral Details

Please complete the below.

Patient coming with radiographic template?

Denture Marked

Seperate Template

Is the patient pregnant?

Yes

Area of Interest

Both Jaws

Maxilla

Mandible

Sectional / Quandrant

Right

Left

Right

Left

Justification for X-ray

Implants

Impacted Teeth

Airway Assessment

TMJ

Ortho

Bone Grafting

Endodontics

Sinus Exam

Oral Pathology

Perio

Image Upload

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Clinical Indications

Referrer Declaration

Please confirm by ticking all boxes below before submitting

I confirm this scan is clinically justified under IRMER17 and the benefits outweigh the radiation risk.

I have the necessary training to interpret this scan, or arrangements are in place for a qualified report.

The patient has given informed consent for this scan to be carried out.

I understand it is my responsibility to review and act on the scan findings.

have provided all relevant clinical information to support this referral.

I consent to have this website store my submitted information so they can respond to my inquiry

Preferred Practice Location

I have read and agree to the Terms and Conditions and Privacy Policy

I agree to Treeline Dental (Head Office) using my personal data to keep me informed about dental treatments, marketing offers, and initiatives that may be of interest, and to share this information with relevant providers within the group.

Preferred Practice Location

I have read and agree to the Terms and Conditions and Privacy Policy

OPG and CBCT Referral to Treeline Dental Care

OPG & CBCT Referral Form

Patient Details

Referring Dentist Details

Referral Details

Referrer Declaration

Make an Enquiry

Make an Enquiry!

OPG and CBCT Referral to Treeline Dental Care

OPG & CBCT Referral Form

Patient Details

Referring Dentist Details

Referral Details

Referrer Declaration

Call Reception

Make an Enquiry!