Which practice is your referral for?* Glenholme Dental Centre (Basingstoke) Wordsworth House (Romsey) Please note our CBCT scanner is based at our Glenholme practice in BasingstokePatient DetailsName MrMrsMissMsDrProf.Rev. Title First Name Surname Patient Date of Birth* Day Month Year Patient Address*Patient Postcode* Patient Phone Number (Home) Patient Phone Number (Work) Patient Phone (Mobile) Patient Email Referring DentistDentist Name* Dentist Telephone Practice Address*Dentist Email* Practice Postcode* Referral DetailsMedical HistoryReason for referral and justification for CBCT ScanExamination Request for Dental CBCT All CBCT scans will be supplied on secure USB FlashdrivesPrice Options OPG £45 CBCT Scan only (no report) £100 CBCT Scan with Single Arch Report £175 CBCT Scan with Upper & Lower Arch Report £200 Note that all our CBCT scans are full upper and lower arch imagingDo you have additional files to send in support of this referral? Yes No How will you be sending attachments? By email Attached to this form By post File Attachments Drop files here or Select files Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 64 MB. EmailThis field is for validation purposes and should be left unchanged. This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.