Causeway Street, Moffat DG10 9DN Mon–Wed 9:00–18:00 · Thu–Fri 8:30–17:3001683 220753

FOR DENTAL COLLEAGUES

Referrals

We accept OPG and CBCT imaging referrals from practices across the region. Images are captured and returned to you digitally; reporting remains the responsibility of the referring dentist.

OPG

Panoramic radiograph, returned to you digitally.

CBCT

Cone beam CT, returned to you digitally. We do not report on completed scans.

TO MAKE A REFERRAL

Complete the form below and we will be in touch to arrange a scan date.

Fields marked * are required.

STEP 1 OF 3

Referring dentist

PRACTICE NAME DENTIST'S NAME * DENTIST'S GDC NO. * DENTIST'S EMAIL * CONTACT NUMBER *

PRACTICE ADDRESS

STEP 2 OF 3

Patient details

PATIENT'S FULL NAME * PATIENT'S DATE OF BIRTH * PATIENT'S PHONE NUMBER * PATIENT'S EMAIL ADDRESS

PATIENT'S ADDRESS *

STEP 3 OF 3

The scan

RELEVANT MEDICAL HISTORY REASON FOR REFERRAL AND JUSTIFICATION FOR THE SCAN *

REGION OF INTEREST *

Maxilla Mandible Both Small section

CBCT REPORT *

I understand Moffat Dental will not provide reporting on completed scans.

We will contact the patient directly to arrange a scan date and copy you in.

PREFER TO PHONE?

01683 220753, Mon–Wed 9:00–18:00, Thu–Fri 8:30–17:30

BY EMAIL

contactus@moffatdental.co.uk

Causeway Street
Moffat DG10 9DN
contactus@moffatdental.co.uk

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OPENING HOURS

Mon–Wed 9:00–18:00
Thu–Fri 8:30–17:30
Sat (hygienist) 9:00–13:00
Sun closed

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