Sovereign House
First Floor
153 High Street
Brentwood
Essex CM14 4SD

T: 01277 205605
E: info@sovereignhousesdc.co.uk
www.sovereignhousesdc.co.uk

Panoral / CBCT Scan Referral Form
Fees - The fee is payable by the patient at the time of the scan

Radiographs should provide information to confirm a diagnosis, or provide information that may affect the choice of treatment.

Relevant points from history, examination, radiographs (please enclose copies of any radiographs of the area under investigation)

Thank you for your referrals