CBCT Referral

Practice Details

Patient Details

2D Imaging

• Digital Panormamic (OPG): Please Choose... Yes No
• Extra Oral Bitewings: Please Choose... Yes No

How would you like to receive the image?

• Memory Stick: Please Choose... Yes No
• Secure Server: Please Choose... Yes No

Area of interest - CBCT only?

• Enter all CBCT information here:

Justification for OPG / CBCT:

• Pre Implant Assessment: Please Choose... Yes No
• Wisdom Teeth: Please Choose... Yes No
• Other: Please Choose... Yes No

I’d like to be informed of exclusive offers and other practice information YES

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