RADIOLOGY REFERRAL Referring Clinician * Referring Practice * Referring Practice Email * Patient Details * First Name Last Name Patient Contact Number * (###) ### #### Patient Email * Who is paying for referral * Referring Practice Patient Referral Service * OPG CBCT Scan Details of Referral * Justification for Radiograph * Radiologist report * I will be reporting on the radiograph myself I would like a radiologist report (additional £120 fee) Thank you!
