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Radiographic exposure request

Patient details
patient's title: (required)
patient's surname: (required)
patient's first name: (required)
patient's address: (required)
patient's town: (required)
patient's postcode: (required)
patient's date of birth: (required)
patient's contact phone number: (required)
Additional details
type of radiographic exposure: (required)
clinical content for requesting this radiographic exposure: (required)
relevant results of history, clinical examination and other imaging: (required)
what information do you want the radiographic exposure to provide?: (required)
define the anatomical area that the radiographic exposure should cover: (required)
I can confirm that I am trained and competent in dental alveolar reporting and will report and record on this radiographic exposure appropriately:
I can confirm that I would like Balbirnie Oral Care to provide a report on this radiographic exposure at an additional fee of £15 to the patient:
Referring dentist details
name: (required)
email: (required)
address: (required)
town: (required)
postcode: (required)
contact phone number: (required)
NHS list number: (required)
date: (required)
Verification
verification code: (required)
verification image


2019 Balbirnie Oral Care
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2019 Balbirnie Oral Care
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2019 Balbirnie Oral Care