Referral Form Don’t USE – Soni Dental Implants

Dr Mukesh Soni
Soni Dental Implants 1 Oriel Court 106 The Green Twickenham Middlesex TW2 5AG

Tel: 020 3292 0580

Please, be informed to let your patients know that CT scans are payable on the day of the scan.

CT Scan Fees: £150/1 Arch. £200/2 Arches

Patient Name

Patient Address

Patient Postcode

Patient's Mobile Phone No.

Patient's Home Phone No.

Patient's Email

Patient's Date of Birth

Referring Dentist Name

Referring Dentist's Practice Address

Date of referral

Referrer's Email

Referrer Phone Number

The clinical context or requesting a CBCT examination

Relevant Results of history, clinical examination and other imaging

What information do you want the dental CBCT examinations to provide?

Define the anatomical area that the scan(s) should cover*

JUSTIFICATION - Name of the IRMER practitioner

Date

Signature

Details of scan authorised

SCAN INFORMATION - Name of Operator

Date

Signature

Exposure of factors used

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