X-ray referral

Name: Pallant Orthodontics
Telephone: 01243 532 304

If you need to refer your dental patients for X-rays at our practice, please fill out our referral form below:

Please fill in all fields marked with *

Name*

Practice Name*

Email*

Phone*

Referral Type Private Patient

Name*

Phone*

Date of Birth

Address*

Email*

Possibility of pregnancy Yes No

Examination required Dental Panoramic Lateral Cephalogram

Purpose of examination*

I will make my own reporting arrangements

Comment*

For further information about how we use your data, please see our privacy policy

Visit Us

Choose the best practice for you! We have 2 locations perfectly located in Chichester and Bognor Regis.

11 North Pallant,
Chichester
West Sussex PO19 1TQ

Best car park: Chichester Cattle Market - PO19 1JW. Approximately a 5 minute walk through town to the practice.

Opening Times

Weekends - we are always contactable via the Dental Monitoring app!

60-62 London Road,
Bognor Regis
West Sussex PO21 1PT

Opening Times

Weekends - we are always contactable via the Dental Monitoring app!