CBCT Scan Referral Form

Use this form to refer a patient to Poldent Dental Care for a CBCT (cone beam CT) scan. Once we receive the referral, our reception team will contact the patient to arrange the scan.

Data is sent over a secure connection directly to the selected practice and is not stored on the website.

Referring clinician
Patient details
Referral details

If referring for CBCT scan please specify the area and justification. Also confirm referring dentist qualifications (at least Level 1); proof of qualification will be required.

Do not attach X-rays or documents here. After we receive the referral, we will tell you how to send them securely.

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