CBCT Referral for Vitality Fairfield

We welcome referrals from the dental community with convenient access to a team of dental services including: Endodontics, CT Scans, Perio, Ortho and Implants.

Collectively, we offer a patient-focused, multi-disciplinary approach to complex dental problems with the aim of achieving the best possible outcome for your patient.

Vitality Fairfield
Wellburn Road, Fairfield, Stockton-on-Tees, TS19 7PP

01642 587 646

tcofairfield@riverdalehealthcare.com

CBCT Form

Please fill in this multi-part form below with as much detail as possible.

Fields marked with an * are required.

Title

Patient Name

Patient Address

Postcode

Date of Birth

Tel: Home Phone

Tel: Work Phone

Tel: Mobile Phone

Patient Email

Preferred method of contact

Dentist Name

Dental Practice

Practice Address

Postcode

Phone Number

Brief Patient History:

Reason for Scan:

All scans will be parallel to the occlusal plane unless otherwise specified. Radio-opaque to be worn?

Yes No

Field of view (CBT Scan Charges):

Small Field (50X50mm) £103.00 Full Upper (80X50mm) £242.00 Full Lower (80X50mm) £242.00 Dual Jaw (80X90mm) £330.00

Dentist Signature

Dentist GDC Number

STANDARD IMAGE RESOLUTION WILL BE SUPPLIED UNLESS YOU SPECIFICALLY REQUEST HIGH RESOLUTION OR ENDO (80X50mm FOV only)

Reports: Indicate your preference for radiological interpretation of the dento-alveolar region:

I undertake to report on the scan required by IR(ME)R 2000/2006

I accept

Assistance with planning:
Assistance with case planning at Vitality Dental Care: Price on application.
YOUR PATIENT WILL BE ASKED TO PAY FOR THEIR SCAN AT THEIR APPOINTMENT.

Vitality Fairfield

Wellburn Road,
Fairfield,
Stockton-on-Tees
TS19 7PP

CBCT Referral for Vitality Fairfield

CBCT Form

Vitality Fairfield

01642 587 646

Out of hours – call practice number above

vfreception@riverdalehealthcare.com

FREE Consultation

Dentist Area

0% Finance Available

Dental Plans

Contact Us

Dental Treatments

Dentist Area

0% Finance Available

Dental Plans

Contact Us

Treatments