Referral Form printable pdf download

Referral Form

CBCT Dental Imaging Planning Center

REFERRAL FORM

PATIENT INFORMATION:

Name: ____________________________ DOB:________________ Male ____ Female ____

Tel: _______________ Email: ______________ Address/Town: __________________________

Today’s Date: _____________ Appointment Date/Time: ____________Consult Date: ________

SPECIFY EXAM:

□ Implant Mandible (specify site) __________

□ Implant Maxilla (specify site) ______________

□ CBCT Panoramic View

□ Orthodontic Assessment

□ Impaction (specify site) ___________

□ Endodontic Assessment □ Sinus Assessment □ Airway Assessment

□ TMJ

□

□ EASY GUIDE

□ DICOM ONLY

3D NOBEL GUIDE SOFTWARE

SPECIFY FORMAT:

SPECIAL INSTRUCTIONS:

□ Includes Radiologist’s Report $75.00

□ Remove Prosthetics Scan in: □ resting (non-occluding) position

□ tight occlusion

REFERRING DOCTOR:

Name:____________________________________

Signature: _______________________

Tel: _____________________________________

Specialty: ________________________

Address: ________________________________

Email: __________________________

PLEASE CALL US AT 508-285-8301 TO SCHEDULE YOUR PATIENT. PATIENT NEEDS TO BRING

THIS REFERRAL FORM OR FAX THE FORM TO 508-285-6014.

100 West Main Street Norton, MA 02766

508-285-8301

Referral Form