CBCT/OPT Radiograph Referral Form
Please complete this form to refer a patient for a CBCT or OPT radiograph.
Referring Dentist's Full Name
*
First Name
Last Name
Referring Dentist's Email Address
*
example@example.com
Referring Dentist's Phone Number
*
Please enter a valid phone number.
Format: 0000 000 0000.
Patient's Full Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Email Address
example@example.com
Patient's Phone Number
Please enter a valid phone number.
Format: 0000 000 0000.
Relevant Clinical Notes / Medical History
Attach Supporting Documents (e.g., previous radiographs, referral letter)
Upload a File
Drag and drop files here
Choose a file
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of
OPT Request
OPT View Required
Please Select
RIGHT OPT
LEFT OPT
FULL OPT
Sectional BWs
Justification
CBCT Request
Site of Interest
Clinical Indication
Please Select
Implant Planning
Endodontic Assessment
Impacted Tooth Assessment
Oral Surgery Planning
Assessment of Pathology
Assessment of Periapical Pathology
External/Internal Resorption
Trauma Assessment
Orthodontic Assessment
TMJ Assessment
Sinus Assessment
Assessment of Anatomical Structures
Failed Implant Assessment
Pre-prosthetic Assessment
Other
CBCT View Required
Please Select
5x5
5x10
10x10
MAR?
Yes
No
ANR?
Yes
No
Previous Imaging Available?
*
Yes
No
Reporting
Reporting
*
Yes – Please provide a report
No – I will report myself
No – Report will be arranged elsewhere
Declaration
Declaration
Level 1 CBCT Training Confirmed (for CBCT referral only)
Referral contains sufficient clinical information
Patient has consented to referral
The patient is aware of the fee for this
Submit Referral
Should be Empty: