This online Cone Beam CT Scan Booking Form is for referring dentists’ use only.

Information you enter here including patient contact details is secure and will be used solely for the purpose of booking a CBCT scan. Please see data protection notes below

If this is the first time you have used our CBCT scanning service please take the time to read our service terms and conditions and health and safety compliance.

You will automatically receive a copy of this form via your designated email.

If you require any further information or help in relation to completing this form please call us on 01242 655554

Fields marked with an * are required

To ensure that we are not caught out by the occasional technical glitch if a member of the Arnica team has not contacted you within 48 hours (2 working days) of completing this form please call us on 01242 655554

CBCT Booking Form

Fields marked with an * are required

Referral Dentist Details

Patient Details

Referral Details

Radiographic Stent

If a radiographic stent is required please note that the IR(ME)R referrer is responsible for supplying a stent that is accurate and fits correctly prior to the scanning appointment.

Reporting of scans

(Please select one of the following)

(Or)

Dentist declaration

Scan return

Submission

Once you have checked that the information you have provided above is complete and accurate please click Submit Form below.

If you have omitted required information form will fail to submit notifying you of the specific error/s

A copy of this referral form will be automatically forwarded to your registered email address

A member of the Arnica team will then contact your patient to arrange an appointment

You will be notified by email of the appointment date and time

Please note failure by patient to attend appointment will incur a £50 surcharge

Anti-spam Question

Data Protection

This website is secured via SSL so that the information you enter here is transferred to us securely via encrypted email. On receipt of this form we will  then create a patient record within our EXACT patient management system and upload any radiographs you have attached as well as a scan or PDF version of this form. All other copies are then deleted.

We will not share in full or in part any information provided above with any third party unless explicitly requested to do so in writing by either you – the referring GDP, or the patient.

For more information about how we protect your data and that of your patients please see our Privacy Notice (link to privacy notice)