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Dental Clinic - Le Dental
Dental Clinic - Le Dental
Dental Clinic - Le Dental

Refer your patient to [le] Dental

I am referring to

I am referring to:
Oral Surgeon - Marco Benigni
Dr Ani Kalustian (General and Aesthetic Dentistry)
Oral Surgeon - Marianne Heine
DWSI Duncan Grant ( Endo)

Patient details

Patient title* 
Mr
Mrs
Miss
Ms
Patient Date of birth
Day
Month
Year

Referring dentist’s details

Referral date
Day
Month
Year

Detailed reason for referral:

Please select how you would like to refer:

Online
By Email
Dental Clinic - Le Dental
Imaging

Refer to us by email

Please email details on hello@ledental.co.uk with your digital x-rays and photos that you feel appropriate along with either a covering letter or a completed scanned copy of our referral pro-former.

Imaging Online Referral form for [le] Dental

Referring Dentists Details

Patient Details

Patient Date of Birth
Day
Month
Year
Possibility of Pregrency?
Yes
No

Payment

Examination Required

Digital OPG X-ray
Include TMJ
Yes
No
Normal or Ultra Low Dose
Normal
Ultra Low Dos
Itero 3D Scan
Cone Beam CT Scan
Normal/Ultra Low Dose/ Endo mode 75microns
Normal
Ultra Low Dose
Endo mode 75microns
My patient will wear a stent
Yes
No
Upper Jaw/Lower Jaw/Upper and Lower jaw/
Upper Jaw
Lower Jaw
Upper and Lower jaw

Sectional

Upper Left
8
7
6
5
4
3
2
1
Upper Right
8
7
6
5
4
3
2
1
Lower Left
8
7
6
5
4
3
2
1
Lower Right
8
7
6
5
4
3
2
1

Delivery options

What format would you like the requested CBCT scan in?
Do you require a report by a Dental Radiologist for your scan? ( added £120 to cost of scan if Yes)
Yes
No
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