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Menu
Home
About
Meet The Team
Information for Patients
Blog
Practices
Glencairn
Heathfield
Glenside
Treatments
Dental Implants
Composite Bonding
Tooth Whitening
Invisalign
Root Canal Treatment
White Fillings
Dentures
Veneers
Crowns
Bridges
Facial Rejuvenation
Hygiene Services and Periodontal Treatment
Fees
Private Fees
NHS Fees
Finance
GlenPlan Memberships
Contact
Referrals
Implant Referrals
X-RAY
Endodontics
Emergencies
Referrals - X-Ray
Clinician
Clinicians Name
(Required)
Position
(Required)
Clinicians Email
(Required)
Dental Practice
(Required)
Consent
(Required)
I agree to the Terms & Conditions for the prescription of radiographs and Glenscan
Patient
Patient's Name
(Required)
Patient's Contact Telephone Number
(Required)
Patients Date of Birth
DD slash MM slash YYYY
RMH Checked and nothing contra-indicatory
Pt not Pregnant
Pt consent achieved
Is the patient claustrophobic
Is the patient to wear a Radiographic template:
None - £0
Maxilla - £25
Mandible - £25
Both - £40
Area of Interest
OPT - £72.50
Mandible 6cm - £99
Maxilla 6cm - £99
Both Jaws 10cm - £180
UL Quad - £72.50
UR Quad - £72.50
LL Quad - £72.50
LR Quad - £72.50
Small FOV - £72.50
Total
Justification
Clinical Context
Results of history, clinical exam or other imaging
What information do you want the exam to provide?
Do you require
Pathology Report - £45
Radiology Report - £95
3D Model - £350
Signed
(Required)
Date
DD slash MM slash YYYY
