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Gerrard House | 43-45 Theobald Street | Borehamwood

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CALL 0208 706 0060

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About
Implants
- Single Dental Implants
- Full Arch Dental Implants
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- Patient Referral Form
- CBCT Referral Form
News
Contact

About
Implants
- Single Dental Implants
- Full Arch Dental Implants
Straightening
- Invisalign^®
Cosmetics
Pricing
Referrals
- Patient Referral Form
- CBCT Referral Form
News
Contact
CALL 0208 706 0060

CBCT Referral Form

Refer your patient to SMILEWELL

Simply complete the form below in as much detail as possible and a member of our team will get back to you!

Referring Dentist DetailsPlease provide details of the referring dentist below.

Dentist First Name *

Dentist Last Name *

Dentist Phone Number *

Email Address *

Patient DetailsPlease provide as much detail about the patient below.

Prefix

Patient First Name *

Patient Last Name *

Patient Phone Number *

Patient Email Address *

Patient Date of Birth *

Day *

Month *

Year *

Patient's Gender *MaleFemale

Payment Type *DoctorPatient

Earliest date to scan the patient *

Referral DetailsThe Radiographer will take a scan with the lowest dose, smallest field of view and best resolution, according to the area of interest and clinical indications, in line with IR(ME)R and ALARP. The age, anatomy and physical build of the patient are all dependent factors.

Please select which services you require for this Patient: *CBCT Scans2D Imaging

Teeth ChartPlease indicate teeth and area of interest, if no areas are selected the whole jaw will be scanned.

Upper LeftUL1UL2UL3UL4UL5UL6UL7UL8

Upper RightUR1UR2UR3UR4UR5UR6UR7UR8

Lower LeftLL1LL2LL3LL4LL5LL6LL7LL8

Lower RightLR1LR2LR3LR4LR5LR6LR7LR8

CBCT InformationPlease indicate details of CBCT scan requirements below. Please note that we only provide DICOM files for the CBCT

Is the patient coming with a radiographic template? *YesNo

Clinical Indications *

Please choose an option *

Do you require a CBCT report? *YesNo

Does reduction technology required? *YesNo

Justification for X-ray (multiple choice) *ImplantsEndodonticsSinus LiftBone GraftRamos Bone GraftOrthodonticsOral PathologyTMJPeriodonticsChin Bone GraftImpacted TeethSinus ExamZygomatic ImplantsAirway Study

I agree to my personal data being used as per this website's Privacy Policy. *Accept this notice

Please do not fill in this field.

Meet The Team

Clinical
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Admin

Clinical Director/ Founder

Dr Adeel Ali

Senior Associate

Cosimo Meucci

Associate

Magdalena Rybak

Associate

Anmol Patel

Hygienist

Abigail Needleman

Head Nurse

Daniela Bartic

Dental Nurse

Maggie Ginga

Laboratory Technician

Guida Martins

Practice Manager

Uma Depala

Senior Treatment Coordinator

Hayleigh Brady

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