CBCT Referral & Requisition

CBCT Referral & Requisition
Referring Clinician
Referring Dr.*
Office Phone*
Office Email *
example@example.com
Please Note: Metallic jewellery, partial dentures and hair clips will need to be
removed for the scan.

For female patients, please advise us if you think you may be pregnant.
Patient
Name*

First NameLast Name
Patient Phone*
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Circle or illustrate the area to be scanned
Tooth Number/s*
Indications for Scan*

Implants / Implant MappingWisdom TeethSalivary GlandDisease/Syndrome/Tumor /TMJFacial/Muscle Pain/Paralysis/Abnormal SensationPainful/Cracked/Troublesome Teeth (Endodontic)Impacted/Delayed/Extra/Malpositioned Teeth
Relevant Clinical Details and History *
Should be Empty:

Referring Clinician