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Imaging Referral Request

Lorem Ipsum Dolor

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Patient Details

Patient Date of Birth*

Referring Dentist's Details

Has the patient attended Heathwood Dental Practice before?

Referral Details

Reason for Image Request
Type of Image Required*
Region of Interest*
Is a radiological report required (Please note an additional fee applies)*
Are there additional copied of the scan on CD required? (Please note, this service is chargeable)
Who is paying for the image(s)?*
Do you have any files you wish to attach in support of this referral? (Radiographs/Clinical Photos)*

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