Referring Dentist Name *Please complete this field.Dentist Email *Please complete this field.Dentist Phone *Please complete this field.Patient Name *Please complete this field.Patient Email Patient Phone Referral Reason Oral surgeryDental implantsOrthodonticsEndodontics (root canal)Other — see notesReferral Notes X-Ray / Image Upload 1 JPG, PNG, TIFF, PDF, DICOM or a ZIP — up to 25 MB each, three files. A study exported straight off a PACS or a CD often has no file extension (IM_0001, DICOMDIR); those cannot be accepted, so put the study in a ZIP and send that instead.X-Ray / Image Upload 2 X-Ray / Image Upload 3 Leave this field blankPrefer to talk it through? Phone 01473 254 873, or find us at 49 Fonnereau Rd., Ipswich, Suffolk, IP1 3JN.
