Radiographic Exposure Request

Patient Details

Patient's Title *

Patient's Surname *

Patient's First Name *

Patient's Address *

Patient's Town *

Patient's Postcode *

Patient's Date of Birth *

Patient's Phone Number *

Patient's Email Address *

Additional details

Type of radiographic exposure:*

Clinical content for requesting this radiographic exposure (justification): *

Relevant results of history, clinical examination and other imaging: *

What information do you want the radiographic exposure to provide? *

Define the anatomical area that the radiographic exposure should cover: *

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:*

Referring Dentist Details

Name *

Email *

Address *

Town *

Postcode *

Contact Number *

Date *

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