CBCT Referral

Welcome to the White House Dental CBCT Referral Service. We are committed to providing referring clinicians with high-quality CBCT imaging, prompt reporting, and a seamless referral experience. Please complete the referral form below with all relevant patient and clinical information to help us process your request efficiently. If you have any questions, our team will be happy to assist.

To ensure a smooth referral process, please download and review our Service Level Agreement (SLA) before submitting your referral. Once completed and signed, please upload the agreement using the attachment section of this form.

*White House Dental only accepts CBCT referrals from dental practices. Patients referred for CBCT imaging will remain under the care of their referring dentist.

white house dental bushey heath

Referring Dentist Name

Referring Dentist Phone Number

Referring Dentist Email Address

Referring Dentist Address

Patient Title

Patient Name

Patient Date of Birth

Patient Phone Number

Patient Email Address

Patient Address

Clinical context for requesting a dental CBCT examination

Relevant results of history, clinical examination and other imaging

What information would you like the dental CBCT to provide?

Define the anatomical area that the scan(s) should cover

If you would like to attach radiographs, clinical notes, and evidence of level 1 CBCT training, please use the upload facility below. The file types to upload are JPEG, PNG, PDF, and ODT

Click or drag files to this area to upload.

Reporting of Scans

Dentist Declaration

These guidelines are available on: https://assets.publishing.service.gov.uk/media/5a7d4f13ed915d321c2de451/HPA-CRCE-010_for_website.pdf