Dental CBCT Referral Form

PATIENT DETAILS

Name

First Last

DOB

MM slash DD slash YYYY

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name (please fill it different from above)

REFERRER DETAILS

Referring Dentist Name

Clinic Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number

REFERRAL DETAILS

Reason for referral:

Anatomical area/ teeth to be scanned:

Radiographs

Take as needed

Sent with patient

Attached

Emailed

Mailed

Date taken:

MM slash DD slash YYYY

Additional comments

Reporting of the scan:

I wish Georgetown Sleep Dentistry to provide me with a basic report on my patient’s scan.

I wish Georgetown Sleep Dentistry to provide me with a report and treatment plan on my patient’s scan.

Future Treatment:

Please send this patient back.

Please accept this patient for treatment and send back for regular recalls

Please accept this patient for all future treatments.

174 Guelph St. Georgetown, ON L7G 4A7

Phone: (289) 891-6669

Fax: (289)-891 -6698