CBCT Referral - Dentist Edinburgh - Slateford Dental Care

Patient Details

Patient's Name *

Patient Email *

Patient's Date of Birth *

Patient Phone Number (Mobile) *

Patient Phone Number (Home)

Patient Phone Number (Work)

Patient's Address

Street Address *

Address Line 2

City *

County *

Post Code *

Referring Dentist

Dentist's Name *

Dentist's Email *

Dentist's Phone Number

Dentist's Address

Street Address *

Address Line 2

City *

County *

Post Code *

Scan Details

The reason you would like the scan *

The area the scan should cover *

Information you would like from the scan *

Details of radiographs contained with referral *

Is it a stent to be worn? *

Yes No

Referring Dentist - Preferred method of contact *

Phone Email Letter

Do you have additional files to send in support of this referral?

Yes No

File Attachments

Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 512 MB.

Confirmation

I confirm I have signed the Service Agreement with Slateford Dental Care. I understand it is my responsibility to report on the CBCT scan.

I have read and agree to the Privacy Policy, and consent to Slateford Dental Care contacting me about my submission.

Come and see us

0131 337 2689
appointment@slateforddentalcare.com
51 Slateford Road, Edinburgh, EH11 1PR
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Monday: 8:30am – 5:30pm
          Tuesday: 8:30am – 5:30pm
          Wednesday: 8:30am – 8:30pm
          Thursday: 8:30am – 5:30pm
          Friday: 8:30am – 5:30pm
          Saturday: By Appointment