CBCT referral form

CBCT REFERRAL FORM
PATIENT INFORMATION
Patient Name

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Email
example@example.com
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Date Submitted

MonthDayYear
Date
REASON FOR REFERRAL
Tooth Number
Area
Field of View Size (THE FOV MAY BE ADJUSTED BY THE AUTHORIZED CBCT MEMBER BASED ON CLINICAL ASSESSMENT AND ROI NEEDS):
Resolution
Additional Information
COMPLETED SCAN INFORMATION
Date Received

MonthDayYear
Date
Date Patient Contacted

MonthDayYear
Date
Date of Scheduled Scan

MonthDayYear
Date
Reporting Provided By
Date Patient Notified of Reporting Information

MonthDayYear
Date
Reporting Information Added to Patient Chart
Note
Referring Dentist
Signature
Should be Empty:

CBCT REFERRAL FORM