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Ultra Low Dose CT Scanner

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Download PDF - CT Scanner Form

Patient Details

Date of Birth

Payment

Area of Interest CBCT only

Is the patient coming with a radiographic template?
Is the patient possibly pregnant?

(If no teeth are selected the whole jaw will be scanned)

CBCT FORMAT

CBCT OUTPUT

EXTRAS

2D IMAGING

2D OUTPUT

(If Referral)

Intra oral scanning - trios 3 colour

Clinical indications: (mandatory)

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Registered office: C/O TG Associates 7 Jardine House, Harrovian Business Village, Bessborough Road, Harrow, Middlesex, HA1 3EX

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