Dental Referrals

Dental Referrals

At Winchester Orthodontic Practice, we value the trust placed in us by our referring dentists and are committed to providing exceptional specialist care for every patient you send our way. Whether you are referring for a CT scan or specialist orthodontic treatment, our team ensures a smooth, transparent, and collaborative process from start to finish.

Dentist Details

Dentist Name(Required)

First Last

Practice Name(Required)

Practice Email(Required)

Practice Address(Required)

Street Address Address Line 2 County Post Code

Patient Details

Name

Title First Last

DOB(Required)

Parents Name

First Last

Patient Address

Street Address Address Line 2 County Post Code

Patient Phone(Required)

Patient Email(Required)

Comments

Patient Records

Do you have an OPG or equivalent available?(Required)

Yes

File

Drop files here or

Max. file size: 200 MB.

Patient Details

Name(Required)

Prefix First Last

DOB(Required)

Address(Required)

Phone(Required)

Email(Required)

Notes(Required)

Referring Dentist Details

Dentist Name(Required)

Prefix First Last

Practice Name & Address(Required)

Practice Phone(Required)

Practice Email(Required)

Dentist Signature(Required)

Print Full Name

GDC Number(Required)

Reason for Scan and Justification(Required)

CT Scan Requirements

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque markers to be worn? Yes/No(Required)

SCAN ON CD

Please supply a radiologist’s report

Memory Card

I undertake to report on the scan as required by IR (ME)R 2000/2008

CT Scan Charges(Required)

Single arch/endo – £150

Dual arch – £230

Ceph – £95

OPG – £85

Orthodontic Referral Form

CT Scan Referral Form

Dentist Details

Patient Details

Patient Records

Patient Details

Referring Dentist Details

CT Scan Requirements

Monday	8:30 am - 5.00 pm
Tuesday	8:30 am - 5.00 pm
Wednesday	8:30 am - 5.00 pm
Thursday	8:30 am - 5.00 pm
Friday	8:30 am - 12.30 pm