Refer a Patient – Kana Health Group

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Refer a Patient

Patient's Details

Patient's Name

Address

Date of Birth

Email

Mobile Number

Referral required:

Select the referral

Implants Orthodontics CBCT Restorative Dentistry Other

Please choose the type of scan(s) required

3D CBCT scan 2D OPG

Clinical Justification for X-rays:

Implants (specify expected teeth/sites ) Bone Graft Impacted teeth Endodontics Sinus Exam TMJ Oral Pathology Orthodontics

What CBCT Field of View (FOV) would you like?

Full maxilla Full mandible Both jaws Small FOV (5x5 cm) High resolution small FOV (Endodontics only) Not applicable (OPG only)

Will the patient be wearing a radiographic stent?

Yes No

Radiographic report?

I will make my own reporting arrangements I would like the patients radiographic examination to be reported (£150)

Details of referral and specific teeth(s) required for scan or treatment

Referring Dentist

Referring Dentist's Name

Practice Address

Referrers Email address

Referrers Phone Number

Which Practice You Want To Refer?

GDC/GMC Number

About us
Locations
For patients
For Dentists
Partnering with Kana

The Academy - Kana Health Group
Station House, 11 Station Rd, Newport Pagnell MK16 0AG, United Kingdom
07740 083 913

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