Doctor Name: Practice Name: Email: Phone: Date:
RELEVANT XRAYS (PA, BW, PAN) MUST BE INCLUDED FOR ALL PATIENTS, AS PER RCDSO. All metal in the head/neck needs to be removed for the scan.
Patient Name: Sex:MaleFemaleOthers Date of Birth: Address: Email: Phone: Dental History & Medical Alerts:
Implant PlanningImpacted TeethTMJ AnalysisPathological LesionEndodontic PurposesOthers, Please Explain:
Full ReportDICOM Files OnlyBoth
UR PostUR AntLR PostLR AntUL AntUL PostLL AntLL PostRight TMJLeft TMJ
1817161514131211212223242526272848474645444342413132333435363738
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Please email the completed form to info@robertsonfamilydentistry.ca or Tel: (613) 829-2222 www.robertsonfamilydentistry.ca 2017 Robertson Rd, Ottawa, Ontario, K2H 5Y7
