Referral Form Smile Store

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We offer use of our iCat Cone Beam CT scanner and our OPG X-Ray machines to other dentists for diagnostic purposes.
Dental professionals are welcome to complete the referral form with their patient’s details, and we will contact the patient to book an appointment for diagnostic imaging.
OPG X-Rays will be emailed to the referring dentist. CT scans will be burned to a disc and given to the patient or posted to the dentist as requested.

    Patient Information






    Reason for Referral

    • Digital Panoramic X-ray (OPG)

    • Digital Lat Ceph X-ray

    • CBCT Scan

      • Maxilla

      • Mandible

      • Both Jaws

      • Radiological Report Required

    • Diagnosis

    • Treatment

    • Other

    Referring Dentist/Doctor Information