Oral Radiology Referral SCOMS

Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Additional/alternate phone number

Area CodePhone Number
Date of Birth*

MonthDayYear
Health Care Number (Patient)
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:

PathologyImplantsTooth localizationEndodontics
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 $400.00
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 $500.00
Interpretation of existing CBCT (Please provide Dicom Images for review)

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CBCT Interpretation $200
Upload of Dicom images here ->
Should be Empty: