Referral Form Patient Name Date of Birth Phone Number Date Report Who to Bill? Who to Bill? Bill Dr. Bill patient 3D Cone Beam Computed Tomography (CBCT) - Field of View 3D Cone Beam Computed Tomography (CBCT) - Field of View Single Site (5cm x 5cm) Single Jaw Both Jaws Tooth Number(s) Which Jaw Which Jaw Upper Jaw Lower Jaw Reason for Scan Service Needed Service Needed Implant(s) / Graft Guided Surgery Orthodontic Sinus/ Airway Endodontic TMJ Post Op Pathology Radiology Report Required? Radiology Report Required? Yes No Digital Radiography Special instructions / Relevant clinical history Dr. Name Dr. Email Dr. Signature Date Submit
