Market Hill, Rothwell, Kettering, NN14 6BW

01536 710075

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Referrals

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Referrals

Have you been
referred to us?

If you would kindly enter your details in this form, we will be in touch.

If unsure, just give us a call instead.

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1Referral type

2Referring dentist details

3Patient details

Referral Type

Implants

OPG

CBCT scans

Cosmetic treatment

Attach Radiographs

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB, Max. files: 5.

CBCT Requirement

Field of View

Please state which tooth

Sectional (50x50mm) E.g UR6, UL5

Returning CBCT Scan to Referrer

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

Please provide a radiologist report

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

Returning CBCT Scan to Referrer

Please tick whether you would like it sending by DICOM or DCM file

DICOM

DCM

CBCT Scan Charges

CBCT Scan: £100.00

Radiologist Report: £75.00

YOUR PATIENT WILL BE ASKED TO PAY FOR THEIR SCAN AT THE APPOINTMENT UNLESS YOU INSTRUCT US OTHERWISE.

Patient informed of approximate cost

OPG Justification

Implant Treatment Planning

TMJ

Orthodontic Assessment & Planning

Endodontic Assessment

Impacted Teeth Assessment

Other (Please Specify)

Please Specify

OPG Charges

OPG: £60.00

YOUR PATIENT WILL BE ASKED TO PAY FOR THEIR SCAN AT THE APPOINTMENT UNLESS YOU INSTRUCT US OTHERWISE.

Patient informed of approximate cost

authorise

I hereby authorise Trinity Dental to carry out an OPG on my behalf. The results of the radiograph will be returned via email. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Trinity and the operator will not be responsible for assessing the OPG for the suitability of treatment of for immediately identifying and referring pathology; by referring this patient I am accepting this responsibility. I certify that I have obtained the necessary qualifications in order to refer and evaluate the data requested by me and provided by Trinity Dental. I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security.

Additional comments

Dentist Name

Prefix First Last

Postcode(Required)

Date of Referral

DD slash MM slash YYYY

Mobile

Telephone

Email(Required)

Signature(Required)

GDC Number

Patient Details

Patient Name

Prefix First Last

Gender

Date of Birth

DD slash MM slash YYYY

NHS number

Address(Required)

Street Address City County Postcode

Mobile(Required)

Telephone(Required)

Email(Required)

Relevant Medical Details(Required)

Short summary of case(Required)

INSIDE TRINITY DENTAL

Our Gallery

Our Surgery

PHONE

Reception: 01536 710075

EMAIL

[email protected]

ADDRESS

Market Hill, Rothwell, Kettering, Northamptonshire NN14 6BW

Our Services

Dental Hygiene
Tooth Straightening
Emergencies
Teeth Whitening
Dental Implants

Opening Hours

Monday - Wednesday: 8:00 am to 5:00 pm
Thursday: 8:00 am to 8:00 pm
Friday: 8:00 am to 4:00 pm
Saturday: 8:00 am to 1:00 pm (Alternative)
Sunday: Closed

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Market Hill, Rothwell, Kettering, NN14 6BW

[email protected]

01536 710075

Referrals

Have you been referred to us?

CBCT Requirement

Returning CBCT Scan to Referrer

Returning CBCT Scan to Referrer

CBCT Scan Charges

CBCT Scan: £100.00

Radiologist Report: £75.00

OPG Justification

OPG Charges

OPG: £60.00

Patient Details

INSIDE TRINITY DENTAL

Our Gallery

Our Surgery

PHONE

EMAIL

ADDRESS

Our Services

Opening Hours

Have you been
referred to us?