We offer a referral service for both 2d and 3d radiography. Offering pre-bookable and a walk in service for patients needing Cephs, Opgs and CT scans. Please complete the following form.Alternatively you may download the referral form, complete and give to your patient to bring with them.

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Referring Practitioner

Practice Address*

Patient Details

DD slash MM slash YYYY
Patient Address*

Medical History

Possibility of pregnancy*

Examination Required

Upper teeth
Lower Teeth
Panoramic
Digital cephalometric
Region of interest
Cone beam CT

Case description

Software Options for Cone Beam CT Scans
Delivery Options
Drop files here or
Max. file size: 2 MB.
    Please note: All photographs submitted to us will be kept strictly confidential and not shared with any third party. IRMER 2000 Regulations: London Smile Clinic does not routinely report upon scans and radiographs. To comply with the IRMER 2000 regulations all radiographs and scans are required to be reviewed and reported into the clinical notes by the referring practitioner or by a radiologist. London Smile Clinic strongly recommends that all CT and other radiographic examinations should be reported upon to rule out the possibility of coincidental pathology.
    This field is for validation purposes and should be left unchanged.

    Referral charter

    1. Expertise

    Our aim is to ensure that both the referred patient and you, the referring dentist, are delighted with the quality of our clinical expertise and the level of care and attention they receive from us.

    2. Trust

    We will only carry out the treatment previously agreed with the referring dentist. We will always refer patients back for any other treatments, unless you request otherwise.

    3. Choice and consent

    After the initial consultation, we will always provide the patient with a written treatment plan, a copy of which is always sent to the referring dentist. No treatment will be carried out without an estimate of fees given to the patient.

    4. Care

    In the rare event where complications arise after the patient has been treated by us, we will always ensure that they receive the remedial care they require immediately.

    5. Support

    Our aim is to ensure that as part of your extended dental team, we can add extra value to the overall patient experience you offer. We will support you and your patient every step of the way.

    How can we help you?

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