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Dental CT Scan

Please enter your practice details:-

Patient details:-

Patient contact details. These are the details we will use to contact your patient and ensure that they are booked in as smoothly as possible.

Please indicate which of the following you are referring for:-

3D CBCT Scan Please Indicate Area of Interest
Both Jaws
Mandible (lower Jaw)
Maxilla (Upper Jaw)
Panoramic X-ray
Please give details of justification for CBCT Scan or Panoramic X-ray

Please enter the referring practitioner details.:-

This will act as the signature, hereby authorising City Dental, 26 Albion Place, Leeds to carry out a 3D CBCT Scan or Panoramic x-ray on your behalf.

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