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
PathologyImplantsTooth localizationEndodonticsOther
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)

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

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

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

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

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CBCT Scan $450.00

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Implant Scan $500.00

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Orthodontic Scan $550.00

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CBCT Interpretation $250.00