Dental CBCT Scan Referral Form

    Referring Dentist






    Patient Information







    Indication/s for scan

    Requested format of the scan

    Region to be scanned

    Please click or circle the region of interest

    Additional Comments/Clinical Information/Suspected Diagnosis

    Please email the completed form to info@robertsonfamilydentistry.ca or Tel: (613) 829-2222
    www.robertsonfamilydentistry.ca
    2017 Robertson Rd, Ottawa, Ontario, K2H 5Y7