SCOMS - Oral Radiology Referral

Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone Number

Area CodePhone Number
Land Line Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Additional/alternate phone number

Area CodePhone Number
Date of Birth

MonthDayYear
Provincial Health Care Number (Patient)
Provincial Health Care Number
Referring Dentist or Doctor

First NameLast Name
Referring Doctor Office Location
Referring Doctor's email
example@example.com
Referring Doctor's Postal Code

Street Address

Street Address Line 2

CityState / Province

Postal Code
Referral Reason:

Other
Description/sites/pertinent information for radiologist
Please note: All CBCT acquisitions will include a corresponding report in accordance with CDSA regulations.
3D ICAT SCAN: (*includes radiology report)

Rows Pick one

CBCT Scan $450.00
3D IMPLANT PLANNING SCAN: (*includes radiology report & site measurements).

Rows Pick one

Implant Scan $500.00
3D ORTHODONTIC PLANNING SCAN: (*includes image portfolio and tracing)

Rows Pick one

Orthodontic Scan $550.00
Interpretation of existing CBCT (Please provide Dicom Images for review)

Rows Pick one

CBCT Interpretation $250.00
Upload of Dicom images here ->
Should be Empty: